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On Unrelated Symptoms & Patient Advocacy

Posted May 26 2012 4:24pm
Sometimes you think you know, but you really don't. Other times you convince yourself you don't know, but you actually do. But the moments when you're absolutely sure you know...well, those are the ones you have to hold onto and refuse to let go. Let me explain...

It was my second month of Internal Medicine, way back in September. I was in the process of admitting a new patient and I was running through the review of systems. His chief complaint was lower back pain, but as I was fresh out of second semester and the words of Bates were burned into my brain, I went down the line from head to toe uncovering any other symptoms that may have been hidden. He had mentioned a recent change in vision, a suddenly appearing red spot or floater that had started a day ago in his right eye. He didn't think it was related to the back pain, but I made a mental note of it.

I visited him everyday, assessing his back pain. I read through his chart, checked labs and radiological studies, and chatted with the nurses to see how he had been the night before. And each time I saw him, I ran through my standard questions from top to bottom. I asked him about headaches and dizziness. I inquired about his heart and lungs. We talked about belly issues and bathroom visits. And I always asked about his vision. For the first few days he continued to have the same red floater in the same eye, and I would include it in my presentation during rounds. His back pain took center stage, but there was something about his vision problem that stayed with me. And I continued to bring it up during the morning meeting.

"The patient continues to have a red spot in the center of his vision in his right eye. He described it as a lightbulb shape."

"Well, maybe he looked at the lights too long," laughed one of the other medical students at rounds. The table erupted in chuckles, and I politely smiled along with them but there was something about the patient's complaint that didn't set right with me.

The next day I saw him in the morning and I was glad to hear that his back pain had lessened with the medications. But when I asked him about his eyes he said, "Well, now the spot is black and my vision is a little blurry in that eye." Well, this can't be good I thought to myself. I ran through a vision exam, managing to track down an opthalmoscope at the nurse's station. I found the intern that was overseeing his care and reviewed the patient's status with her and my findings during the exam. She agreed that it should be mentioned during the meeting, and I headed out to update the senior resident. When my patient came up during morning rounds, I explained to the attending that the back pain was resolving but I stressed the change in his vision. He consented on obtaining an optho consult, and my intern assigned the task to me.

What seemed like way too much time on the phone, I managed to find out the opthamologist on call - Dr. Smith. Does anyone see the problem here? I think the operator hated me by the end of it because I managed to call every other Dr. Smith in the hospital. The most embarrassing moment was when the operator put me in touch with a Dr. Smith, the hospitalist on the same floor I was on sitting just a few feet away from me. He was not the doctor I was looking for.

Long story short, I finally got in touch with the correct physician, the one who looks at eyes, and I shakily ran through the patient presentation over the phone. He said he would see the patient by the end of the day, and I breathed a sigh of relief. Partly because that seemingly simple phone call was over, but mostly because the patient's vision problem would be addressed and we would find answer to this ocular mystery.

The next day I clambered up the stairwell to the top floor to find my patient's chart and read through the optho note. And there it was, the doctor's assessment in clear handwriting: retinal hemorrhage. The doctor's note explained it all, there were even drawings illustrating what he had found on his exam. The patient would be referred to a retinal specialist.

Most of the time I question myself when it comes to answering questions on the spot. I convince myself that the answer that pops into my head is wrong, it can't be as simple as that. So instead, I freeze or I say I don't know. And then I kick myself mentally when it turns out that I was correct all along. What's worse is that I continue to make that mistake, when I should be learning from it. But when it comes to my patients, I see myself as their advocate and I don't back down from that responsibility. Even though my patient had come in with low back pain, I continually (and perhaps annoyingly to my team) brought up his vision change. They were unrelated symptoms, but at the end of the day, I'm treating a person and not an isolated list of signs and lab values. I didn't care how much I was laughed at and I ignored the eye rolls during rounds. This was a case where I knew something was wrong, and I refused to let it go.

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