- Joined
- Aug 17, 2002
- Messages
- 2,493
- Reaction score
- 1,120
Eh. I was in academics with resident minions, now in community practice just seein' folks myself. Still order just as few tests, don't write z-packs when I know it's not medically necessary, and still have enough 5s on the PG to keep my job.
The pre-test likelihood this 28 y/o is Sick is extremely low. Sounds like LRTI, chances are he Looks Just Fine, and gets a viral syndrome/supportive care talk, follow-up in a couple days. Or you walk in the room and Something Is Really Wrong, but that's going to be 1 out of 50 presentations like this, where there's some other previously undiagnosed comorbid disease blowing this all out of proportion.
Is it PE? Maybe? "Without ordering $3,000 worth of tests, I can't tell you whether you have a clot in your lungs or not. Given your baseline risk and the entire clinical picture, it is more likely this test will falsely diagnose you with a clot you do not have, than actually diagnose a clot you do. Adding in the small additional cancer risk from radiation, an even smaller, but real, risk of kidney damage, doing these tests is more likely to harm you than help." Some people are cray, and you end up doing the tests, but I rarely have folks take me up on tests I don't think they need if I take the time to talk with them.
And then you document "Offered CT r/o PE; patient declined."
The pre-test likelihood this 28 y/o is Sick is extremely low. Sounds like LRTI, chances are he Looks Just Fine, and gets a viral syndrome/supportive care talk, follow-up in a couple days. Or you walk in the room and Something Is Really Wrong, but that's going to be 1 out of 50 presentations like this, where there's some other previously undiagnosed comorbid disease blowing this all out of proportion.
Is it PE? Maybe? "Without ordering $3,000 worth of tests, I can't tell you whether you have a clot in your lungs or not. Given your baseline risk and the entire clinical picture, it is more likely this test will falsely diagnose you with a clot you do not have, than actually diagnose a clot you do. Adding in the small additional cancer risk from radiation, an even smaller, but real, risk of kidney damage, doing these tests is more likely to harm you than help." Some people are cray, and you end up doing the tests, but I rarely have folks take me up on tests I don't think they need if I take the time to talk with them.
And then you document "Offered CT r/o PE; patient declined."