As health care providers, we expect our patients to present us with the clues we need to make an accurate diagnosis. We open the door to an exam room and quickly scan for signs that help us narrow down the massive list of differential diagnoses. So, the single-shoe-and-sock-already-off sign gives us direction. It’s almost easy to believe the patient. After all, they know what they’re feeling, and 90% of our diagnosis comes from accurate history taking. Thank goodness, on the day I entered the exam room and met “Lori,” my antennae were up and receiving. Lori was wrong.
At age 50, Lori had never begun a routine of regular preventive health care. She sought medical attention only as problems arose. She had come to see me because her ankle hurt. Convinced that she had sprained it—or even worse, fractured something—Lori was convinced she needed an x-ray. She actually became irate when I suggested that it was her chest, not her ankle, that I needed to examine.
Lori, a 25–pack-year smoker, began complaining of right ankle pain she had had for weeks. She was uncertain of any specific trauma but was sure that she “must have twisted it somewhere.” The remainder of her review of systems was negative. It wasn’t until I began my physical exam that disturbing cues led me away from her ankle.
When I lifted her blouse to begin a cursory respiratory assessment, I discovered that she was diaphoretic and clammy. She attributed this to her “changes,” and seemed annoyed that I wasn’t paying more attention to her ankle. When I asked her to repeat deep breaths, she became more annoyed and slightly combative. What she didn’t know was that I could not auscultate breath sounds on the right side. I observed that Lori was coughing—a nonproductive but frequent cough. She claimed this was her “smoker’s cough” and an old symptom.
But now her ankle became more interesting to me. It wasn’t her ankle that was causing her pain, I realized, but her slightly swollen calf. This, coupled with her tachycardia, diaphoresis, and abnormal breath sounds, was testing my clinical acumen.
The patient nearly refused a chest x-ray, insisting that her ankle was the problem. Although she was questioning my ability to make a diagnosis, she finally consented to the film and pulse oximetry. Surprisingly, her O2 saturation was 98%, but her chest x-ray showed a massive pleural effusion.
It was time to help Lori understand the seriousness of her condition and the need for emergent hospitalization. Imagine her surprise, when all she thought she needed was an x-ray and a splint! In spite of a thorough explanation of my concerns, Lori stormed out of the office—but not before agreeing to have her brother drive her immediately to our local emergency department (ED).
Later that day, the ED physicians confirmed my worst fears. Lori had not only a deep venous thrombosis in her right leg but a massive pulmonary embolus. CT of her thorax showed one large pulmonary embolus and two smaller emboli, as well as left lung consolidation and significant adenopathy. Her pleural effusion was subsequently found positive for malignant cells, and Lori was scheduled for thoracoscopy for definitive tissue sampling. Because of difficulty weaning her from a ventilator, she remained in the ICU for a few days. But she refused much sedation, preferring to be aware of what was happening; she said she wanted to be able to make her own health decisions.
She was finally weaned, extubated, and sent home to follow up with oncology. Unfortunately, her lung cancer was adenocarcinoma stage IV, and it had metastasized to her bones, liver, lungs, and lymphatics. She consented to a few palliative radiation treatments but ultimately chose to live out her remaining days at home with her family, with analgesia and oxygen support.
Shortly before she died just six weeks later, Lori came in to see me. When I walked into the exam room and saw this woman in mild respiratory distress with her O2 tank in tow, I was stymied. Why was she here to see me? I had kept informed about what was going on with her; I knew that everything possible was being done for her.
But what Lori needed from me was a moment: a moment to apologize for questioning my professional expertise. A moment to apologize for her behavior that day. But mostly, a moment to thank me.
I should be thanking Lori, and I do. I continue to thank her for reminding me that not all ankle pain is musculoskeletal in nature—a concept similar to our credo: “All that wheezes is not asthma.” I thank her for reminding me not to get too involved in what patients believe is wrong with them—and to look at the patient, listen to what they say, and take the time to think outside the box. To slow down, do the detective work, and use our knowledge and experience to come up with the correct diagnosis and plan of care.