Academy of Chiropractic
Narratives 102 N
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
Dr. Studin: What was your question?
Guest: So, me and my colleague, we still have moments where we're working through some cases together. And we're trying to talk about, you know, what's the appropriate diagnosis for given the circumstances. I wouldn't say that the “mild cases” so when they're not like the obvious, when it's more like a Fossette syndrome or some sort of a soft tissue injury or, or what not, depending on the region, we're still trying to nail down what the ideal diagnosis would be in those circumstances.
Dr. Studin: Well, you know, do you have our diagnosis sheet?
Guest: We do.
Dr. Studin: Okay. So you have the cheat sheet that we have with all the relative weights and you understand that you have to understand, you know, and it's funny because I had a conversation with the attorneys from all state distasteful lawyers, I have a regular dialogue with them, we hang out a little bit and they said, yeah, we went after this office, do you know, they use like the same 10 diagnoses and they just recycle them over and over. And there's a pattern there and that's going to be part of our Rico case. I just looked at him and say, you are an xxxx. I said, if you had a cancer surgeon and all they did was colon cancer, they would only have two diagnoses, colon cancer, or not every single patient for their entire career, because that's what they look at. So when we deal with spine, how many diagnosis are we going to really have? You've got strain sprain, you've got a derangement of the spine or subluxation. You've got ridiculous apathy injured in nerve roots, cervicalgia lumbago, you know, by algia myositis and maybe some variations related to the spine. Then you can get it to headaches and migraines and numbness and all that other stuff. But we're going to have the same 20 or 30 diagnoses that we're going to recycle over and over and over, because it's what we traced back to the Oregon that we treat. So with that being said, the question you're asking me is, are you diagnosing it accurately? Are you varying it enough? My answer to you is there's only certain codes within the subset of the organ system that we work with, which is predominantly spine, other than the effects other than other trauma related issues. So, you're going to get cervicalgia lumbalgia myofascitis pain. You can go to numbness, you could go to weakness, injury to nerve root, if there's any radicular types of problems prior to doing a EMG NCV, you can give them to the disc pathology after you have the MRI, you can give them to scoliosis. I mean, there's a tremendous amount of choices that are limited to the organ system you're working with. But I answer your question.
Guest: Yeah. That helps
Dr. Studin: Do you want to ask a more specific question now because I feel like you're not there.
Guest: Oh, no, no. That was helpful. I guess let's use one example then, so, let's just say I've got I'm3 confident that I'm dealing with like a cervical Fossette syndrome. How do you know what to..
Dr. Studin: so, let me just, now I'm going to ask questions because it'll matter when you diagnose it, how do you notice the cervical success syndrome? What's your clinical finding?
Guest Dr: I guess it would be a combination of clinical or the history coupled with what, um, like a coupled with palpation and range of motion.
Dr. Studin: Okay. So, for a pain management doctor to diagnose, if it's says syndrome, he has to do a provocative test stress, the joint, like lean back into it or bend forward and lean back actually. And it hurts then inject, do a joint injection and see if the pain decreases by a minimum of 50%, that's considered an industry standard for a Fossette syndrome.
Guest: So you're just saying based upon how patient you could feel, what they can feel well, more, more so based off of, again, like you, you had mentioned in some of the courses with the history of the heads turned, um, there's a higher likelihood that they can end up with Fossette syndrome. Um, and this term doesn't mean they have it, right? What is your say, hypothetically? They did, they did go get the standards, like you're saying, and someone injected it in and they said that this is a Fossette syndrome.
Guest: What would the diagnosis be? Just that syndrome.
Dr. Studin: Right. But what would the ICDB I don't have that book in front of me. I can't answer that question. Okay. You know, you expect me to know that by heart. What are you on drugs? Well, I I've never seen, I've never, I've never seen the diagnosis. That's why I ask that. Like, I didn't know, go Google Fossette syndrome icy day. So I've definitely done that many times. So that's why I never found one. So that's why. Yeah. Uh, now, now I'll have to go look, you're killing me. You know that you make them all work. So, but the issue is, and just look at it this way. Every time you make a decision like that, you're on the witness. Stand in your mind chapter. And here's the, here's the lawyer pounding away at you. Doctor, could you please tell me the clinical findings, not the symptom, but the clinical finding have that diagnosed that now, are you going to say for Amatol compression because that's not really assessed that's for nerve root, right? Are you going to say I extended the patient and stress their neck and I stress the joint and it hurt more when I did that. Now the question is this to set a radicular?
Guest: Yeah, fair enough.
Dr. Studin: You don't know the answer to those things, right? So I, I really have tended to stay away. Now, if you show me an oblique x-ray and I see that the foramen is encroached, then I'll give it to you. Here's my clinical findings. I'll give it to you. Okay. Just the frame of this encroached. And now I know the process, you know, and then there's pain there. And I did a provocative test for the joint by extending and pressing where I'm not really concerned about ridiculous stuff. Now I have a legally defensible argument that I've documented in my notes to show why I'm concluding the Fossette syndrome. Okay. So you all believe it or not, it always goes back to anatomy. Always, always, always, always. And once you get the anatomy data, then you do a clinical test to verify that you're golden.
Guest: Sure enough. Yeah. That makes perfect sense.
Dr. Studin: Yeah. So my, the way I want to rewire you the think is two words. Legally defensible. If I'm being pummeled by a defense lawyer who wants to rip my head off and wants to take my license away, where is my force field to not allow a mint? It's your documentation of your clinical findings based upon anatomy. And you can never go wrong because then it gets to another word demonstrable because I could show it. And then you are golden and there, and therein lies where your diagnosis becomes rock solid. You have another scenario or is that it?
Guest: Nope, that was it.
Dr Studin: Okay. Call me anytime you need me. All right.