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Diagnostic Decision-Making, Burdens of Proof, and a $6000 per Hour Memory Lapse

Steven H. Horowitz, MD1
[+] Author Affiliations
1Department of Neurology, Massachusetts General Hospital, Boston
JAMA Intern Med. 2013;173(16):1493-1494. doi:10.1001/jamainternmed.2013.8409.
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The goal of clinical diagnostic decision-making is to establish a correct diagnosis with maximal certainty. To this end, tests are often used to supplement the clinical examination and to provide greater accuracy and confirmation. However, given current concerns over health care costs, the sufficiency of each test in each patient’s clinical situation deserves consideration.

For example: In July 2009, my 65-year-old, healthy sister traveled to a friend’s funeral. Following a prolonged period of crying and sobbing, she suddenly experienced memory difficulties and disorientation, repeatedly asking where she was, why she was there, who were the people around her. She was taken by ambulance to a local hospital. While in the emergency department my niece described the symptoms to me via telephone. I diagnosed a well-defined neurological syndrome, transient global amnesia (TGA), and said that my sister would return to normal mentation within hours. I spoke to the treating emergency physician, who independently made this diagnosis, and we mused about its alarming presentation and benign prognosis; virtually all cases resolve completely with recurrences exceptional. My sister’s memory deficits resolved after 6 to 7 hours in the emergency department. Nevertheless she was admitted overnight and underwent a workup with results that were entirely normal.

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Better safe than sorry
Posted on October 5, 2013
David L. Keller
Providence
Conflict of Interest: None Declared
Professor Horowitz is to be congratulated for correctly diagnosing his sister's transient global amnesia (TGA) over the telephone, and for predicting the benign and self-limited course it would take. In my 16 years of practice as a general internist, plus my years of residency training and medical school, I did not encounter a single patient with this condition. Therefore, I sympathize with the internist who was called in to the ER to evaluate this patient. Given an elderly woman who, at first, exhibited total amnesia, including complete disorientation regarding her own identity and surroundings, I would have ordered the same thorough workup that her admitting physician did, unless a neurologist examined her in person and wrote discharge orders. I certainly do not consider the workup to have been excessive or wasteful, even if TGA is rarely caused by embolism or atherosclerotic disease. The prevalence of those conditions is substantial in elderly women, which increases the yield of the tests which were done, making them more cost-effective than would be the case for a young patient with TGA.
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