dx/impressions

Two weeks ago in seminar, we were presented with a case about a patient who had fallen from his ladder while doing some roofing. We were given all the information about him: His objective history, observation, examination results, etc. We were told to, as a group, come up with a single diagnosis and be prepared to present it to the class.

While each group came up with their own suspicion as to what it was, we decided on a secondary supraspinatus strain/tear (semantics) with an underlying supraspinatus tendinopathy. We went back to class and convened for what we thought was large group discussion.

Little did we know, our prof had organized a debate - each two teams would select a representative to speak on behalf of their group and present their case as to why they thought their dx was correct. Our chosen member was Stephen, who bravely went in the hot seat and debated his case according to the findings outlined in the case. He then had to brave the heated questioning of the judges, which included, "If the supraspinatus is your tissue injured, why then is external rotation and internal rotation limited if it only does abduction?" He courageously answered, "Because as the supraspinatus lifts the arm, it also acts to stabilize the humeral head from riding up into the acromion. When the stabilizer fails to act, the entire rotator cuff will behave abnormally and cause an impingement syndrome for which he was already susceptible for with his poor posture and underlying supraspinatus tendinopathy." The entire class whistled - what an answer!

After the entire class had gone through their respective rounds, our instructor Judy gathered us together to give us that one last pep talk. She wanted us to do this exercise because diagnosis is incredibly important - this is what we are doing. She made the distinction that what we did before this program was make impressions - based on our knowledge of physiology, microbiology, anatomy, etc., all we knew how to do was form an idea of what was wrong based on what we were presented with. To make a diagnosis is to make a decision. Here we stand by what we believe is the pathology, and we must be ready to debate our case with client, colleague, lawyer. Diagnosis is the starting point for treatment.

It was at that moment that I felt that what we were doing in this program was no longer trivial manual muscle testing out of a workbook, but that this was real. We will have real patients with real issues, and we will have to take our impressions and form real diagnoses for treatment. People's lives are in our hands.