Is it common to have discrepancy in diagnosis?

[bestcoast]

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I started C&L recently. Most of the cases were simple straightforward.
However, I think I made a wrong diagnosis today?
Woman has advanced cancer with multiple mets admitted for a pathological fracture. We were consulted for competency because she's been refusing imaging, meds on&off.
For her cancer treatment, we can't do anything because it's quite advanced and her tumors are found to be resistant to treatment. So she has already made a DNR decision back in late 2012.
So today, I went to see her. She was quite disinhibited with her breasts exposed and refused any cover/blanket. She was quite tangential especially for a 60 y/o. At one point she even made up stuff about her past businesses that I was able to disprove with a collateral phone convo with her sister. Within 10min of interview, she became distressed, said she wanted to go home without getting a new case and asked me to leave because she was going to nap.
After talking to both her boyfriend and sister, I made a diagnosis of temporary incompentent due to delirium because they both found her to be quite confused and agitated yesterday during their separate visits.
The palliative team went to see her an hour later. She woke up from her nap. They found her to be quite well and not delirious. She was wearing her gown and she was quite clear about her prognosis and diagnosis. She was also willing to get a new cast.

My attending suggested me to rewrite the consult because it's not a good idea to have discrepancy between different services and I should mention about her fluctuating course of her delirium.
I've never been asked to rewrite something before. I kinda feel bad.
Did I do anything wrong? Should I have waited for her to wake up from her nap before I made my diagnosis?

 

[BobA]

I started C&L recently. Most of the cases were simple straightforward.
However, I think I made a wrong diagnosis today?
Woman has advanced cancer with multiple mets admitted for a pathological fracture. We were consulted for competency because she's been refusing imaging, meds on&off.
For her cancer treatment, we can't do anything because it's quite advanced and her tumors are found to be resistant to treatment. So she has already made a DNR decision back in late 2012.
So today, I went to see her. She was quite disinhibited with her breasts exposed and refused any cover/blanket. She was quite tangential especially for a 60 y/o. At one point she even made up stuff about her past businesses that I was able to disprove with a collateral phone convo with her sister. Within 10min of interview, she became distressed, said she wanted to go home without getting a new case and asked me to leave because she was going to nap.
After talking to both her boyfriend and sister, I made a diagnosis of temporary incompentent due to delirium because they both found her to be quite confused and agitated yesterday during their separate visits.
The palliative team went to see her an hour later. She woke up from her nap. They found her to be quite well and not delirious. She was wearing her gown and she was quite clear about her prognosis and diagnosis. She was also willing to get a new cast.

My attending suggested me to rewrite the consult because it's not a good idea to have discrepancy between different services and I should mention about her fluctuating course of her delirium.
I've never been asked to rewrite something before. I kinda feel bad.
Did I do anything wrong? Should I have waited for her to wake up from her nap before I made my diagnosis?

Capacity is task-specific. Only a judge can make decisions about global competency where I live. What was the specific task the medical team wanted you to assess the patient's capacity for? Getting a cast?

 

[splik]

"temporary incompetence" is not a diagnosis and you are not qualified to make a decision about a patient's competency (which is a legal term), but a patient's decision. It would also be inappropriate to say a patient had "temporary" lack of decisional capacity because assessment of capacity is decision specific, and also specific to time, so a patient can have capacity one day and lose it the next.

Another point is that you should not really make an assessment of decisional capacity in the delirious patient. Where possible, this should be deferred until the delirium has cleared. In emergent situations it is irrelevant whether a patient has capacity anyway because in most states you can act in the patient's best interests and do what you need to. Even if she is not capacitous it is unlikely to change the manage because you cant really force someone to have a CT or MRI scan, and if you did under sedation that would likely be unethical and could constitute battery.

The fact that she is refusing things "off and on" may point to a fluctuating delirium. Her inconsistency is consistent with lack of capacity too, as you need to articulate a clear and consistent decision. The question is, is she more crazy to refuse everything, or more crazy to accept. It is highly likely the best thing for this patient IS to refuse all her medications and not to have further imaging. All those drugs are probably making her worse! Patients often improve when they stop their treatment.

You made your assessment at a particular time, and no one can discount that she was delirious at that time as you saw the patient then, and not them. I do not think it is appropriate to change your note if you've already submitted it in the chart. It sounds like your attending is fairly spineless and weak-willed. It would however be appropriate to addend your note to make reference to palliative care's findings which may change your final conclusions, but it doesn't invalidate that she was delirious when you saw her. I don't think that is a discrepancy. You could put something like "Per chart review, patient was more lucid when seen by palliative care and able to engage in discussions and agree to treatment. This is consistent with the fluctuating nature of delirium and will continue to follow for resolution of delirium, though her advanced cancer is an unmodifiable perpetuating factor for her delirium" or something like that.

I also highly recommend you read this article on capacity assessment as you seem to be a bit confused about certain points.

 

[JabsterL]

After talking to both her boyfriend and sister, I made a diagnosis of temporary incompentent due to delirium because they both found her to be quite confused and agitated yesterday during their separate visits.
The palliative team went to see her an hour later. She woke up from her nap. They found her to be quite well and not delirious. She was wearing her gown and she was quite clear about her prognosis and diagnosis. She was also willing to get a new cast.

My attending suggested me to rewrite the consult because it's not a good idea to have discrepancy between different services and I should mention about her fluctuating course of her delirium.
I've never been asked to rewrite something before. I kinda feel bad.
Did I do anything wrong? Should I have waited for her to wake up from her nap before I made my diagnosis?

Unless I'm missing something, I feel like you made the correct diagnosis of delirium in that it sounds the patient is delirius given her fluctuating sensorium and behavioral changes from one time to another. I don't think you should have had to wait to make your diagnosis nor rewrite the original consult, given at the time patient lacked medical decision making capacity..just have the follow-up consult state patient now appears to have medical decision capacity once the delirium in fact totally clears and the patient can give informed consent/refuse interventions with full understanding/appreciation of the risks/benefits/consequences..

 

[billypilgrim37]

Delirium and competency are moment-to-moment determinations. She could be delirious when you see her and not later. That's fine.

 

[hamstergang]

Since everyone is obviously right and there is nothing more to say on the topic at the moment (I can't think of anything besides repeating someone else), I want to make a quick grammatical lesson.

It would however be appropriate to addend your note

I have always said stuff like this too, but one day I looked it up and found that "addend" is not a verb. Addend is actually a noun, pronounced more like add-end, which is defined as one of the numbers being added to another. For example, in 3+4, either the 3 or 4 (or both? I get confused) is the addend.

As hard as I tried, I could not find a single word verb for "make an addendum." While 'addend' sounds correct, I can't find a source to agree that it is.

 

[splik]

As hard as I tried, I could not find a single word verb for "make an addendum." While 'addend' sounds correct, I can't find a source to agree that it is.

You are correct that addend is traditionally a noun that has nothing to do with making an addendum. it is now, whilst not traditional, quite correct to use addend to mean make an addendum. I would say this has to do with the instability of the sign, and the polysemous nature of the English language. If you are a purist (as it sounds like you are), then a synonym would be append.. which you can use to mean 'make an addendum'

 

[vistaril]

I started C&L recently. Most of the cases were simple straightforward.
However, I think I made a wrong diagnosis today?
Woman has advanced cancer with multiple mets admitted for a pathological fracture. We were consulted for competency because she's been refusing imaging, meds on&off.
For her cancer treatment, we can't do anything because it's quite advanced and her tumors are found to be resistant to treatment. So she has already made a DNR decision back in late 2012.
So today, I went to see her. She was quite disinhibited with her breasts exposed and refused any cover/blanket. She was quite tangential especially for a 60 y/o. At one point she even made up stuff about her past businesses that I was able to disprove with a collateral phone convo with her sister. Within 10min of interview, she became distressed, said she wanted to go home without getting a new case and asked me to leave because she was going to nap.
After talking to both her boyfriend and sister, I made a diagnosis of temporary incompentent due to delirium because they both found her to be quite confused and agitated yesterday during their separate visits.
The palliative team went to see her an hour later. She woke up from her nap. They found her to be quite well and not delirious. She was wearing her gown and she was quite clear about her prognosis and diagnosis. She was also willing to get a new cast.

My attending suggested me to rewrite the consult because it's not a good idea to have discrepancy between different services and I should mention about her fluctuating course of her delirium.
I've never been asked to rewrite something before. I kinda feel bad.
Did I do anything wrong? Should I have waited for her to wake up from her nap before I made my diagnosis?

a bad third year med student could figure this one out.....

(sigh)

Capacity is a point in time decision. It seems as if she had capacity at one point, and didn't at another. Case closed.

Capacity evals really don't fit in well with the academic mission of a C/L service. Of course, one could say that capacity evals don't fit in well with psychiatry overall, but that's another thread/discussion we won't get into here......

 

[hamstergang]

it is now, whilst not traditional, quite correct to use addend to mean make an addendum.

Are you British? Just curious based on you using 'whilst,' though it probably doesn't affect anything in this conversation.

I would agree but I just wanted at least one source to agree as well. The only online dictionary that I could find that uses addend as a verb is wiktionary (I actually hadn't searched there for this word before). I guess that site more quickly reflects changes in language than other online dictionaries, so I can feel good about using addend as a verb?

 

[notdeadyet]

Yes, you can use addend as a verb. We love to create verbs from nouns and when there's a linguistic gap, it sticks. You can google this and email me what you find.

I think addend also has the air of authenticity instead of slang because it sounds so much like the verb append.

 

[countryboy75]

I would recommend reading

Beyond capacity: identifying ethical dilemmas underlying capacity evaluation requests.
Kontos N, Freudenreich O, Querques J.

http://www.ncbi.nlm.nih.gov/pubmed/23218060

CL psychiatry is a mentally challenging field, more specifically consults for capacity are a convoluted and arduos task that put strain on everyone.

Delirium by definition "tends to fluctuate in severity during the course of the day" (DSM-V) I agree with making an addendum that the pt wained out of her waxed state of delirium but would not change a diagnosis away from delirium.

Also, as mentioned in the previous posts you need to have a strong understanding of the legal system and terminology while you on on CL. Capacity Vs. competency is a core principle of this and I believe universal throughout the US (at least universal on the PRITE and the boards)

 

[MacDonaldTriad]

At the risk of disrespecting (purposeful use of a noun as a verb) this grammar discussion, don’t make me get out my Luvox prescriptions.😉

 

[SeniorWrangler]

I'd suggest to the primary team that this is a good time for a family meeting to discuss end of life care... If she is expectant, you never know when she might stop having lucid moments altogether. How much imaging and bloodworm is appropriate at this point? Not your call but they should address this if it hasn't been done.