Portal de Periódicos da CAPES

Healing Words

2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 1C Linguagem: Inglês

10.1097/01.eem.0000919312.74677.ae

1552-3624

Mark Mosley,

Nursing Roles and Practices

Using precise language when treating patients helps medical students, residents, and attendings alike zero in on an accurate diagnosisFigureFigureI am a father of five, so one or the other of my children often says something inappropriate, to which I reply with a sharp, “Watch your language. We don't speak that way in this house.” I am sometimes guilty of this same parental tone with medical residents when they misuse certain medical words. I don't address medical students as harshly, but they are guilty by association, like the child who has gone along with his older sibling's bad idea. I must admit that I have resorted at times to a sarcastic smile like the church lady from “Saturday Night Live,” and responded to residents in snarky tones. This misuse of medical language falls into two categories: words used incorrectly and overreaching diagnoses. The following are words that residents often get wrong. These terms are imagined, oxymoronic, inaccurate, or inappropriately applied. Substernal Chest Pain A resident says, “The patient presented with substernal chest pain.” I respond, “Can you point out the anatomical area on the chest that is substernal? Do you mean the patient presented with xiphoid tenderness or epigastric pain? If so, you're no longer really talking about the chest. You mean retrosternal chest discomfort.” Kidney Stone Pain “The patient came in with kidney stone pain,” says a resident. I look dramatically confused and ask, “If we did a CT and found a stone only in his kidney, what would you likely conclude about the patient's pain? Kidney stones don't cause pain. ‘Kidney stone pain’ is an oxymoron. You mean a ureteral stone.” Intrauterine Pregnancy A resident tells me a patient has an IUP consistent with dates. “How old were you when you were a ‘pregnancy?’” I ask. “At less than eight weeks, you were an embryo. At greater than eight weeks, you were a fetus. But you were never a ‘pregnancy’ because that is the condition of the mother. There is no such thing as an IUP. It is an IUE or an IUF.” Running a Temp A resident says, “The kid is still running a temp.” I ask, “Do you know under what conditions a child does not run a temp? It is in the morgue. Do not confuse a temperature with a fever.” More than half of parents who bring their children in make that same mistake. Hypertensive with a Blood Pressure of... “The patient is hypertensive with a blood pressure of 180/100,” says a resident. I wonder how he knows how much of the patient's blood pressure is due to the disease hypertension. “If you slap me in the face and take my blood pressure, do I have hypertension?” I ask. “Or am I just in pain, angry, or scared? Do not assume that elevated blood pressures are the pathophysiological state of hypertension.” Overreaching Diagnoses This next set of terms are not so much inaccurate as they are presumptive. Resident physicians sometimes overreach for a diagnosis instead of remaining humble, and legally safer, in their statements. GERD or Gastritis When a resident says a patient has a past history of GERD or gastritis, I ask if the patient ever had endoscopy. The resident often forgets to ask. GERD and gastritis are often trash-bucket diagnoses made because the patient needed a diagnosis or he responded to a GI cocktail or an antacid in the past, which is a poor predictor of both. The appropriate term is “uninvestigated dyspepsia,” which leaves the differential diagnosis open to other diagnoses, such as non-ulcer dyspepsia, peptic ulcer disease, esophagitis, biliary colic, or pancreatitis. TIA A resident tells me a 22-year-old patient just got out of the hospital with a TIA and that he had similar symptoms that day and should probably be readmitted. “How do we know he was hospitalized with a TIA?” I ask. “Wouldn't illicit drugs, seizures, and somatization also have a normal MRI?” The better term under most conditions is “acute focal neurological deficit - resolved.” A specialist's proclamation of an absent disease does not make it more accurate. Unstable Angina or Vasospasm This is the same argument as TIA except cardiac coordinators want you to use “noncardiac chest pain” when the probability of ACS is low. That way they don't fall out on chest pain workups. I would avoid the temptation to go in either direction for “chest pain that went away.” It is better for the accuracy and integrity of the diagnosis to say “undifferentiated chest discomfort - resolved” in the patient without a heart cath or even in one with a heart cath who had a spasm when the catheter poked the vessel wall. Let the coders worry about which diagnostic code to use. Undifferentiated Abdominal Pain or Irritable Bowel Syndrome A resident says, “All the labs are normal, urine is normal, and the CT of the abdomen with contrast is normal, so I gave her some Bentyl for irritable bowel.” I ask, “According to the American Gastroenterological Association, how does one make the diagnoses of irritable bowel?” (The same argument can be made with the American College of Rheumatology and fibromyalgia). Other tests need to be done outside the ED before you can use a diagnosis of exclusion. We underuse the word “undifferentiated” in the ED. We should use “undifferentiated vomiting and diarrhea” instead of “viral gastroenteritis,” “undifferentiated URI” instead of “sinusitis,” and “undifferentiated headache” instead of “migraine.” We Are All Our Children The great irony of parenting your children to use proper words is they often hear the bad or misused language at home. In this sense, we are all really parenting and teaching ourselves. It is too easy, especially when you are tired and irritable, to resort to inaccurate medical language with the lame adolescent excuse that everyone else speaks that way without getting in trouble. Whether medical student, resident, fellow, physician assistant, nurse practitioner, attending, or senior tenured professor, we must not speak in certain ways in this house. We should bathe our words in accuracy and humility before they get out of the tub of our frontal lobe. As someone once said, “It isn't what we don't know that gives us trouble, it's what we know that ain't so.” Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].