Cowboy medicine or good clinical judgment? Testing minimalism.

MEDICINE & HEALTH/RHODE ISLAND know if I learned anything other than when I make a clinical decision to NOT test, I should be pretty sure of what I’m doing. But I think I knew that before. My next case was a true teaching case. An 80-year old man who had suffered with Parkinson’s disease for over 30 years, now almost completely mute and wheelchair bound, but with only mild cognitive impairment, suddenly became short of breath, with a look of terror. He could not explain what was happening. I thought he may have had a pulmonary embolus. His son reported that his father had been better than baseline for the past few days, had no symptoms to suggest an illness and was quite well until he had been in the office for five minutes seeing the nurse practitioner. His heart and lung exams were normal (as best a neurologist with a cheap stethoscope can judge) and his legs showed no signs of thrombophlebitis. The tachypnea persisted for about 5 minutes and I wondered aloud about sending him to the emergency room, which his son did not want. He calmed down for a minute and then started up again. I was as stumped as I was worried that he was about to die. I could not relate this to his PD, although I suspected it was, and I asked the son to stay with his father and I parked them in an exam room next to the one I was using while I examined another patient. When I checked on him a few minutes later he was back to his baseline, breathing easily, comfortable, with his usual severe parkinsonism. His son explained that his father’s underpants had become too tight and that when he could move himself sufficiently to relieve the discomfort he was back to “normal.” I don’t know how many hours and thousands of dollars we saved, and the decision was certainly made easier by the patient and son’s advance-directives, which excluded emergency room visits, but I wonder how much my 30 years of experience with PD determined the decision to watch Cowboy Medicine or Good Clinical Judgment? Testing Minimalism Commentaries