Upper Thoracic Back Pain – A Case From IM Reasoning

So I just started listening to FOAMcast, a great Emergency Medicine Podcast series. And in that series they mentioned that IM Reasoning was a great Internal Medicine podcast series. And here is a link to the episodes archives [45 episodes at the time of this post].

And I’ve just listened to my first IM Reasoning podcast, EPISODE 45: A COGNITIVE AUTOPSY OF A CASE OF BACK PAIN [Link is to the podcast and show notes], OCTOBER 11, 2018. It is an excellent 45 minute podcast.

And in the podcast we are tasked to always ask ourselves:  “Okay, what is the worst thing that this patient’s complaint could be due to?

And if it turns out that the worst case scenario turns out to be what it is one week from now, will our future selves or our colleagues a week from now agree that what we did was the right thing to do.

Basically the whole podcast goes over trying to figure out the best answer for the above question.

We can hurt the patient by failing to investigate a possible dangerous diagnosis and we can hurt the patient by investigating the patient for a dangerous diagnosis that is very unlikely. And that’s what happened in the case so thoughtfully discussed in this podcast.

Over-investigation of very low probability dangerous diagnoses can expose the patient to dangerous treatment from false positive tests.

Now as we also know from other clinical reasoning talks, we don’t need, necessarily, to evaluate with testing the worst things it could be if the risk of the worst thing it could be is much lower than the risk of false positive diagnosis leading to potentially disastrous  unhelpful treatment exceeds the likelihood failing to diagnose the badness. For two discussion of this problem see my posts:

But getting back to the podcast in IM Reasoning, it is definitely worth listening to. And often by asking ourselves what are the worst things this case could be caused by, we will be led to immediate further evaluation. The whole episode really is about how to go about this thought process.

In the show notes, the speakers make two excellent recommendations:

Here’s a link to the NNT website we reference in the episode. A great resource for likelihood ratios as well as objective evidence-based reviews.

The Rational Clinical Exam publication and on-line series is also highly recommended.

And based on this outstanding podcast, I’ve added IM Reasoning to my list of medical podcasts to follow.

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