Some time ago I saw a patient that came into the clinic with a complaint of cough and congestion that had lasted for longer than the patient was comfortable with. I’ll call this patient, Gloria. Before seeing the patient, I spoke with the attending1 regarding Gloria.
He asked me for my thoughts regarding the differential2, but I didn’t really have a good answer. My first thought was that the symptoms were due to an infection. However, I was already told that this was not the most likely etiology for her symptoms for a couple of reasons: 1) symptoms started about a month ago, 2) blood pressure, temperature, respiratory rate were all within normal range 3) the chest x-ray came back normal, and 4) Gloria’s file showed that she had come in annually around the same time of the year with similar complaints.
At this point, the attending told me that the most likely cause of the symptoms was allergies. And, looking into Gloria’s file I saw that she had a history of allergic rhinitis3. Mentally, I chastised myself for not thinking of allergies. The attending, though, just moved on and ignored my ignorance.
The good thing about being a lowly 2nd year medical student attending clinic is the low expectations — expectations that you probably won’t even be held to. The doctors know that you are still just going through your basic sciences and know that your clinical knowledge/skills still have a ton of room for improvement.
I went to the waiting room, called Gloria inside, and walked her to the exam room. She explained that she had been congested for a month and also had a cough. Her symptoms had a seasonal pattern, occurring around the same time each year. They had also worsened in the days leading up to her clinic visit. This had coincided with the increased winds.
I proceeded to ask for specific symptoms. I asked Gloria about her eyes. I asked if she had any pain. I asked if there was a change in vision. I asked if she had any problems with her eyes. Each time I asked she said, “no.” And so I moved on to other organ systems.
When I finished the interview I listen to Gloria’s lungs. The lung fields were clear with normal breath sounds. Feeling pretty sure it was allergies (and not something more serious like a pneumonia), I left the patient in the exam room and waited for my attending so that we could discuss Gloria’s case.
After reporting my findings to the doctor, he asked if I had done a HEENT exam4. Sheepishly, I told him I hadn’t. Another thing had slipped my mind. He then asked if the patient had any problems with dry, itchy, red, and/or watery eyes since those are common with allergies.
I hadn’t thought about asking specifically, but I told him that I had asked the patient about eye problems in general, and more specifically, about pain and visual acuity changes. She told me she had no complaints about her eye.
Well a few minutes later when the attending pulled Gloria in to see her for himself, he asked her if she had experienced and itching or redness in her eyes. Her eyes lit up. “Why, yes,” she exclaimed.
And I, standing in the corner, shook my head — mentally. Physically, I just kind of looked straight ahead.
Sometimes patients just won’t give you the answers.
- An attending physician is a doctor who as completed his or her residency. See here for more details. [↩]
- I like to compare a differential diagnosis to a lineup of suspects that may be causing the patient’s complaint(s). Click here for Wikipedia entry. [↩]
- Medline Plus: Allergic rhinitis is a collection of symptoms, mostly in the nose and eyes, which occur when you breathe in something you are allergic to, such as dust, dander, or pollen. [↩]
- Head, eyes, ears, nose & throat exam [↩]
