Writing it off or working it up

Recently, I wrote a column on my hatred of the phrase "mini-strokes." And today, I guess I had one (at least as they are often described by my patients).

While catching up on dictation, I meant to type "please forward her labs." For whatever reason, as I tapped away, I accidentally wrote "place" instead of "please."

I knew it was the wrong word and realized it by the third letter, but in the fraction of a second it took to see it, my left fingers finished typing "place" before I could stop them, as if they were on their own. So I deleted the word, retyped it, and went on with my letter.

It was a pretty minor thing. We all do it here and there while typing.

But it’s amazing how many patients will mention such a simple thing to a doctor or go to the emergency department for it. This is, to some extent, our own fault. Organizations heavily publicize "stroke warning signs," which include clumsiness, weakness, and confusion. How you interpret them is going to vary.

What if you’d heard the same complaint in the office? A patient comes in with the same story, presented in terms of "I knew what I wanted to type, but couldn’t make the words come out" or "I couldn’t make my left hand hit the correct keys."

What would you do? Would you write it off as "one of those things" or "we all do that sometimes" (like I did) or would you work it up? Given the nature of our profession, and the risk of a malpractice suit, you’d probably work it up.

How far would this take you? A brain MRI, and likely either a magnetic resonance angiography or a carotid Doppler. You’d probably tack on an echocardiogram for good measure. The more aggressive among us may do a TEE [transesophageal echocardiogram], EEG, and hypercoagulable work-up.

At this point, the mistyped word (or "mini-stroke") has cost at least $5,000 in tests, not to mention the patient’s time off from work to get it all done.

And, of course, we’d also start a daily aspirin. But wait, I already take a daily aspirin. So should I start Plavix? Or Aggrenox? Or Coumadin?

What would you do when your thoroughness finds something incidental? A thyroid nodule seen on carotid Doppler? That will need labs and maybe a needle biopsy. A small aneurysm or meningioma? Those will need annual follow-up studies. A patent foramen ovale? There’s already a 25% chance of finding that right off the top. Are you going to send the patient for a closure? After all, you can’t definitively prove he didn’t have a transient ischemic attack ...

There’s no easy answer here. We try to find a balance between being practical and being competent, with the threat of malpractice sometimes leading us to overkill.

I’m sure some out there will criticize me for trying to be my own doctor by ignoring the "mini-stroke" typing issue. But I’ll hope it’s within the range of everyday human errors (and continue daily aspirin).

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, I wrote a column on my hatred of the phrase "mini-strokes." And today, I guess I had one (at least as they are often described by my patients).

While catching up on dictation, I meant to type "please forward her labs." For whatever reason, as I tapped away, I accidentally wrote "place" instead of "please."

I knew it was the wrong word and realized it by the third letter, but in the fraction of a second it took to see it, my left fingers finished typing "place" before I could stop them, as if they were on their own. So I deleted the word, retyped it, and went on with my letter.

It was a pretty minor thing. We all do it here and there while typing.

But it’s amazing how many patients will mention such a simple thing to a doctor or go to the emergency department for it. This is, to some extent, our own fault. Organizations heavily publicize "stroke warning signs," which include clumsiness, weakness, and confusion. How you interpret them is going to vary.

What if you’d heard the same complaint in the office? A patient comes in with the same story, presented in terms of "I knew what I wanted to type, but couldn’t make the words come out" or "I couldn’t make my left hand hit the correct keys."

What would you do? Would you write it off as "one of those things" or "we all do that sometimes" (like I did) or would you work it up? Given the nature of our profession, and the risk of a malpractice suit, you’d probably work it up.

How far would this take you? A brain MRI, and likely either a magnetic resonance angiography or a carotid Doppler. You’d probably tack on an echocardiogram for good measure. The more aggressive among us may do a TEE [transesophageal echocardiogram], EEG, and hypercoagulable work-up.

At this point, the mistyped word (or "mini-stroke") has cost at least $5,000 in tests, not to mention the patient’s time off from work to get it all done.

And, of course, we’d also start a daily aspirin. But wait, I already take a daily aspirin. So should I start Plavix? Or Aggrenox? Or Coumadin?

What would you do when your thoroughness finds something incidental? A thyroid nodule seen on carotid Doppler? That will need labs and maybe a needle biopsy. A small aneurysm or meningioma? Those will need annual follow-up studies. A patent foramen ovale? There’s already a 25% chance of finding that right off the top. Are you going to send the patient for a closure? After all, you can’t definitively prove he didn’t have a transient ischemic attack ...

There’s no easy answer here. We try to find a balance between being practical and being competent, with the threat of malpractice sometimes leading us to overkill.

I’m sure some out there will criticize me for trying to be my own doctor by ignoring the "mini-stroke" typing issue. But I’ll hope it’s within the range of everyday human errors (and continue daily aspirin).

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, I wrote a column on my hatred of the phrase "mini-strokes." And today, I guess I had one (at least as they are often described by my patients).

While catching up on dictation, I meant to type "please forward her labs." For whatever reason, as I tapped away, I accidentally wrote "place" instead of "please."

I knew it was the wrong word and realized it by the third letter, but in the fraction of a second it took to see it, my left fingers finished typing "place" before I could stop them, as if they were on their own. So I deleted the word, retyped it, and went on with my letter.

It was a pretty minor thing. We all do it here and there while typing.

But it’s amazing how many patients will mention such a simple thing to a doctor or go to the emergency department for it. This is, to some extent, our own fault. Organizations heavily publicize "stroke warning signs," which include clumsiness, weakness, and confusion. How you interpret them is going to vary.

What if you’d heard the same complaint in the office? A patient comes in with the same story, presented in terms of "I knew what I wanted to type, but couldn’t make the words come out" or "I couldn’t make my left hand hit the correct keys."

What would you do? Would you write it off as "one of those things" or "we all do that sometimes" (like I did) or would you work it up? Given the nature of our profession, and the risk of a malpractice suit, you’d probably work it up.

How far would this take you? A brain MRI, and likely either a magnetic resonance angiography or a carotid Doppler. You’d probably tack on an echocardiogram for good measure. The more aggressive among us may do a TEE [transesophageal echocardiogram], EEG, and hypercoagulable work-up.

At this point, the mistyped word (or "mini-stroke") has cost at least $5,000 in tests, not to mention the patient’s time off from work to get it all done.

And, of course, we’d also start a daily aspirin. But wait, I already take a daily aspirin. So should I start Plavix? Or Aggrenox? Or Coumadin?

What would you do when your thoroughness finds something incidental? A thyroid nodule seen on carotid Doppler? That will need labs and maybe a needle biopsy. A small aneurysm or meningioma? Those will need annual follow-up studies. A patent foramen ovale? There’s already a 25% chance of finding that right off the top. Are you going to send the patient for a closure? After all, you can’t definitively prove he didn’t have a transient ischemic attack ...

There’s no easy answer here. We try to find a balance between being practical and being competent, with the threat of malpractice sometimes leading us to overkill.

I’m sure some out there will criticize me for trying to be my own doctor by ignoring the "mini-stroke" typing issue. But I’ll hope it’s within the range of everyday human errors (and continue daily aspirin).

Dr. Block has a solo neurology practice in Scottsdale, Ariz.