DX^ **(Under Construction)**
Differential diagnostic infinite page; bc it never ends. DDX never ends, that is the truth. Carry that truth.
& Dx momentum is a real problem: anything in the hx is where anyone will start. Has to start, unfortunately. Perhaps defensible in most emergent crises. But it can start here.
This is especially a problem for chronic care. This leads to Hickams Dictum Errs, at a minimum. Unfortunately, the Lit is also more just shuffled letters than not. & even good research has translational issues. & even translated good research never tells you where on the curve you are.
Therefore, rule out everything from the start, again, & re-eval (in pts you actually love) every 3-5yrs. Guidelines will flip monthly/annually. Large changes every ~5yrs. Thf – oldest doctor/oldest treatment.
In emergency, whatever the main lead physician is most comfortable w/should lead; with few exceptions.
Never expect other specialties to have done their job. Especially for psychiatric Dx of exclusion rule out. They will choose a conclusion and run out the clock. It is how medicine is taught (another reason why entering a clinic “w/a past Dx” is so dangerous – it will more oft than not lead to the final conclusion, rather than informing as a single data point. EHRs are a problem for this reason as well).
Everyone gets serial ekg, serial tropes (for chest pain). Everyone gets a CXR. Everyone gets blood glucose checked. Everyone gets thryroid ruled out. Everyone gets at least one MR, to rule out “slap you in the face” lesion, for consideration. Preferably 2 @ 12 months apart. Everyone gets thiamine and b12.
All smokers moved to vape nic.
Ketamine, when fentl or morph alone will work, is dumb. Psych hx is a problem. Neg fx are not mapped. Unknown encoding LT psych issues – that you wont see manifest in the ED – are a concern. RespDep does occur in higher dose. Ocular pressure is another. Oldest Rx that already work in a given setting are better, in all cases – ie opiates here. Miracle discoveries never are. No-one is coming to the ED for opiates, not enough to change practice for the population. That is not a clinical problem. Opioid tolerant ketamine was already used: it isnt most cases. All studies will exclude ne1 relevant, & claim Ket is a miracle for everything from here on in. The ground work & pre conclusions are set. Ket will, in reality, be used as an adjunct in the end anyway, i suspect – ie w/opioids. Thf fewer Rx are better. & established Rx are better. Stick w/the opiates, over a combination, if the addition of ket is for no real reason.
Xam wise, as w/anything – to save a life=leeway. After that, start from scratch:
1) Dont over irradiate. If they are conscious, & not due for surg, they probably dont need a CT. In the 3rd bracket age & on thinners w/trauma (even mild) – idc. Thats fine. Watch the “look/find” rule tho. Know what you’ll do w/ the result.
2) But iff there are symptoms un-managed, that interfere w/flourishing – MR. Be aware of the “dont look, bc youll find” rule. Bc it is real. But w/time, and “trial/err go to’s” (TRG2s) dont bring an optimal self – at least have a look in the magnet.
3) Again, iff no mgt “successful”. Define “success” w/pt. & only to find a new tac: ie everything is done only w/an intent to change Tx.
4) Check medication clashes; Rx and diet clash; Rx-likely relevant dose non-compliant; depression //compel beh rules being applied.
5) Always remember: the new answer may be “right-er”, for a period of time in life, for a pt – but best guess action towards “best optimal self” is a moving target. As “self” alts.
6) Less is almost always more in med. Bal unchanged better than expecting something “new” will be better, and worth an Rx change. “No breaky/no fixy” rule applies. From AntiDs to opioids – dont just monkey w/things. Unless the pt is asking.
7) HTone is ^. Daily life outcome that is “not optimal” is, by definition, sub optimal care. Life is risk. Mitigate it. (*Mitigate life. What could go wrong? Maybe rephrase this.)
8) Trust gestalt intuition of oldest doc. Unc/Pro is faster & more complete. Slow walk thru can come later. Or assess intuit post, but start there.
9) & DX^ always applies. Even going back to a previous Dx.
10) There are no new cutting edge Rx or procedures: only items even more understudied than usual looking for participants in panic. unless you are running the trial, &/or paid by the company, the answer is no.
11) It is remarkable how many things self resolve. Or ‘we dont know’, bc once “things” are “found“, they “have” to be treated. Also, nothing has proper follow up or validation. On purpose, in the Lit. Laziness, in the clinic. This requires a systemic solution.
This makes going to get a medical opinion, when they are saying we shouldnt even treat pain now, more a dangerous waste of time than anything else in most situations.
12) Know your pre-test probabilities, population, & what you would do w/a test result. Or dont order it.
*Everything in objective medicine, is subjective. Even w/i specialty. Up to, & including, “oh g*sh, their f**king head fell off“. Remember that.
*There are no perfect studies; & that is OK.
But not trying for a reasonable study design, w/i acceptable limitations: this is not OK. Neither is rolling over when things clearly do not make sense, but are being widely promoted. The “runaway train fx” rule. Every1 expects some1 else ‘checked’. They didnt. Or ‘a million smart ppl cant be wrong’ – as god is my witness (praise be upon him): a million ppl can be oh so very wrong. It is not even uncommon.
Make sure things are base rational yourself. Nothing new or suddenly popular is good. Ever.
*Surg is surprisingly effective in most cases. Case dependent of course. But as a wide rule, surg w/ mod pain relief for life is oft better than str8 up life long “pretend targeted” on label Rx – company only trialed – FDA/TGA scammed recomended Tx.
*Benzos b4 Neurolepts. Opioids alone b4 Ket combinations.
*Be skeptical of anything that announces itself as the Rx of choice, or that had to be legally compelled for sale/use. Bc this is “guaranteed return” forever-free money – & that breeds corruption.
It is like getting a text book on the curriculum list. Your text book is not the ‘best’ of all knowledge available on any topic, or the only view, especially in light of the most recent research: & you g*sh d*rn know it. But you still want the money, plus it is in print already now. Same thing applies everywhere else.
*All research is to have a (1/3/9 &…) 12mnth min follow up & replication in-built. A smattering of weeks quasi follow up for healing/recurrence is not good science. i mean g*sh d*rn obviously.
Everything is about goal focus, which are, in order: A) Best optimal daily self, starting tomorrow, & most lilyPi days & B) Youre always treating the whole social unit (family/income/access ect). This is part of the Dx/Sfx. & C) This is treating society. Worry about the case in front of you. Data is far too poor, in every field, to pretend there are society wide best practice anythings anywhere.
fib/flutter/cardiac gen mnr: currently CA+chBlocker NOT adenosine. & avoid zap as long as possible (tho it appears to work…but nagging feeling that it is causing a re-occur damage), if there is an alt that is not life long med (iff not already).
Aspirin as minor thinner IS still the way to go. Ignore all that noise
Abscess: InD w/irrigate AND AB coverage. No packing. No loop. This changes bi-monthly – no. This is the correct pcol.
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