Thursday, November 15, 2007

Listen, the patient is telling you the diagnosis

There's an old saying attributed to Sir William Osler that you'll hear dozens of times even one year into medicine:

Listen, the patient is telling you the diagnosis.

We've also been told that if you've done an extensive list of investigations and still don't know what the patient has, re-taking the history can sometimes bring a diagnosis to light.

Being able to spend time in clinic is great, but to be honest, we don't really know what questions to ask yet. Yeah, we know a few: does it hurt? how much? where? and for how long? But it takes a long time and a lot more training to learn all the important associated conditions - that I should ask the patient with Crohn's disease if their joints hurt, or the patient with chronic hypertension how their vision is.

Some of these things come second nature for doctors who have been doing this for years, but when you're new at this, you feel like getting a diagnosis just by asking the patient a few questions can be pretty difficult.

Getting the diagnosis from the history has started happening to me, though. At my clinical exam at the end of the year (the OSCE - Objective Structured Clinical Exam) where medical students go from room to room at the sound of the tone, read the instructions on the door, then either take a history or do a physical while an examiner watches, there was one station I won't forget - I figured out what the patient had, just by asking the right questions.

She presented with a cough. As I asked her more and more questions, I was able to determine that she had been coughing up blood, and she had been exhibiting what are known as constitutional symptoms - fever, weight loss, and fatigue - all indicating a serious, chronic condition. As I finished asking her my questions, it began to dawn on me in my head... oh my gosh, lady, you've got lung cancer... and you've probably only got a few years left to live.

Okay, yeah, the patient was an actor, and it was a strucutred environment, and that was the point of the entire exercise, but it was still a neat feeling to almost be certain about a patient's diagnosis just by asking her some questions.

I was pretty excited about my success. Inevitably, however I came crashing down to earth while chatting about that patient with another student.

I'm still kicking myself - as I spoke with my friend I realized I didn't ask the patient the most obvious respiratory history question:

"Do you smoke?"

I won't make that mistake again.


jysika said...

Well, at least you figured it out!!!

How do you break it to a patient that they have cancer? It must be hard...

Anonymous said...

Here in Iran TB would sure be on the differentials too. And I SO know what you mean by not knowing enough to ask the Q's that need to be asked. I'm exactly there right now. I mean, I know a lot about DM, but putting them all together and trying to find out about them reterograde is truly hard.

Anonymous said...


Anonymous said...

it must be hard indeed to tell a pationt he`s suffering from cancer..

i hate to be the carier of that awfull news..