Diagnosis

The history and physical exam are the heart of medical diagnosis. The great diagnosticians of the past like Sir William Osler are remembered because of the symptoms and signs they discovered: Osler's nodes, Osler's triad, Osler's sign. And in the age of great technologies, we must remember that talking to the patient and laying hands on them are free and often much more revealing than a set of blood tests or films. Indeed, the old school approach to a sick patient often aids us in selecting what laboratory and radiologic tests we need. In my other blog Case of the Day, I try very much to capture the curiosity, fascination, intrigue, and excitement about diagnosis.

However, anesthesia is very different than medicine as practiced in the physician's office. The patient is asleep and nonresponsive; we get no history and our physical exam is limited. Our laboratory tests and other studies are limited and often not available in the time frame we need them. So when something unexpected happens intraoperatively, diagnosis can be difficult. We learn to listen to the ventilator to understand what the patient's lungs are saying. We learn to do intraoperative echocardiography to examine the heart. We learn to look at the urine to extrapolate information about the kidney. We can use a crude EEG to understand the brain. We have to know how the patient's pre-operative conditions, surgery, and intraoperative interventions and medications may interplay to make one diagnosis more or less likely than another. It's a detective mystery with our hands tied behind our back; we learn to use all our instincts and judgment to keep a patient safe.