Last updated: February 19, 2013

Medical diagnosis: You don’t have to be a doctor or a nurse to understand this

Medical diagnosis: You can understand this without any prior medical knowledge

Medical diagnosis

Image courtesy of: National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)

As a licensed Internal Medicine physician working in a community hospital in Nebraska, I love the close and personal nature of doctor-patient communication that happens during our hospital rounds.This close and trustful relationship inspired me to teach my patients everything I knew about their symptoms and medical diagnosis. To my surprise, I realized people without any medical background can understand very complex medical concepts if you tell it to them in a language they understand. When the complex medical issue at hand relates to the the real person in the patient’s room, it becomes personal. People’s ability to understand things improve significantly when it relates to someone they know.When patients understand the details of the medical diagnosis, they become better equipped to work together with the doctor.I was amazed to discover how diagnostic accuracy and patient outcomes improve when doctor and patients work together. This is the main goal of my book project: to teach patients the details of how medical diagnosis is made by telling them the real stories of patients they can relate to.

Medical diagnosis: Diagnosis follows correct analysis of symptoms

As a hospitalist working in the ICU, I have had several real life experiences to convince me that accurate and timely medical diagnosis literally makes the difference between life and death. When patients describe their symptoms clearly and accurately to the doctor, they greatly increase the chances of getting the right medical diagnosis. I will describe the story of a real patient that I admitted to the ICU on my on-call day to illustrate how a timely medical diagnosis can save a life.

It was a cold winter afternoon in a hospital in the Midwest. The patient was referred to me from a smaller hospital in a nearby rural town. He was assumed to have symptoms consistent with seizure. A seizure is an abnormal brain activity that results in involuntary and sudden movement of certain parts of the body or even the whole body. Although it can be any type of spontaneous involuntary activity, it mostly presents as shaking or flailing with sudden fall and some degree of confusion or change in mood or behavior. That patient was a previously healthy male in his 50’s. He was just about to get out of his house and was walking towards his garage. Luckily for him, his wife and his son were with him when he had that unfortunate event.

The seizure was witnessed by the man’s wife and son. He was taken to the rural hospital. They did a CAT scan of his head when he reached there. The CAT scan was completely normal. This was not surprising as many patients that have seizures do not have anything  visible on a head scan that can explain the seizures. The doctor then reassured him and was planning to send him home but he had a hunch that the medical diagnosis did not make complete sense.

Medical diagnosis: When the diagnosis is clear but something does not make sense, seek help

The patient was still complaining of being slightly lightheaded when he tried to stand up. Although it is usual to have some confusion following a seizure, it is very unusual to get lightheaded. It sure was an unusual symptom for the medical diagnosis. The doctor was somewhat alarmed by this combination of his symptoms and had some doubts about the medical diagnosis. Everything checked out fine except for the fact that he had a slightly lower than normal blood pressure. “It was just a little bit lower than normal. If the patient did not have any symptom, that blood pressure could have been considered a low normal,” the good doctor tried to reassure himself.

Subsequently, he put everything together. The seizure, the lightheadedness and the low blood pressure together seemed like some kind of an unusual combination of symptoms for the medical diagnosis of seizure. The doctor, therefore, decided that the patient deserved a second opinion from a specialist. He wanted to consult a Neurologist– a specialist of diseases of the brain and the nervous system. Neurologists have special training in seizures and related diseases. I was the on-call doctor in the nearest regional hospital that day accepting outside transfers. I am not a Neurologist but we did have Neurologist available in the hospital to consult on the case.

Medical diagnosis: Making correct diagnosis requires careful thinking

As the patient arrived in the ICU, I was immediately alarmed by the appearance of the patient. I, too, had a hunch that something was seriously wrong with the patient. Most doctors get this kind of gut feeling about the seriousness of the illness by just looking at the patient. It is something we all feel at some point. But we are not able to explain it in any specific scientific terms except for saying “the patient appeared stressed” or “patient looked very sick”. As I said,the rural family doctor also had a similar hunch that influenced his decision to send this patient out for further investigation to explore the medical diagnosis. As it turns out, we need to listen to our inner voice when making critical decisions about medical diagnosis.

That is probably why they call medicine half art and half science. Sometimes, science can not completely explain how doctors make decisions based on their gut feeling.
When I examined the patient, I , too, was concerned about the slightly lower blood pressure. I then went ahead and asked the patient, his son and his wife about the details of the incident. Luckily, I noticed a rather peculiar aspect of the story. They were all describing the event exactly as it happened. Normally, that means everyone is very accurate in describing the event. But, in this case, it struck me as somewhat odd.

Medical diagnosis: Always look for the subtle clues

In most patients with medical diagnosis of seizures, I had to rely on someone other than the patient to get the exact sequence of events. The patients themselves were mostly confused after the event or had at least some lapses in memory during the event. That was the fist clue I noticed that made me think twice about the medical diagnosis. Then I asked the patient if he had any confusion or loss of memory or even just a slight clouding of his thought during the event. His answer was a strong “no” to all of my questions. I then asked him to tell me the exact feeling he had when it first started. The few words that he told me next gave me the second clue in making the right medical diagnosis. He said, “I was feeling normal as I was walking towards the car. Within a fraction of a second, I suddenly felt very weak and lightheaded. I was so weak I fell to the ground and started shaking my arms and my legs. I felt like I was too weak to even control my own hands.” So far everyone had been focused on “what happened”. I suddenly changed my thought process and asked what exactly did the patient feel like when it happened.

Medical diagnosis: If the diagnosis does not make sense, think again

Medical diagnosis

Image courtesy of: National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)

After I heard his story, I had a sudden realization. The medical diagnosis was not seizure. It had to be something related to the blood supply to his brain. The patient felt something, some catastrophic event in his body that happened within fractions of a second that caused him to collapse into the ground. Something that sudden with such an impact on the whole body had to be related to blood supply. If the blood supply gets cut off suddenly, the body collapses. When the blood supply to the brain gets interrupted, you get a stroke. But this was clearly not a stroke. With a stroke, you only get symptoms from the loss of blood supply to a part of the brain. But he had more than just loss of blood supply to his brain. He had a major loss of blood supply to his whole body. It had to be something in his chest, either his heart or his lungs or one of the major artery coming out of his heart.

As soon as that thought came to my mind, I immediately ordered the nurses to stop everything they were doing and rush the patient to the CAT Scanner. The nurses were taken by surprise and thought I had a long day. They reminded me that he had the CAT scan of his head already done at the other hospital. I said, “I know, I want a CAT scan of his chest, stat!”. They looked perplexed. In a last bid to put some sense to the thing, they looked at me and said, “But, doctor, his medical diagnosis is seizure which happens in the brain, not in the chest.” I said, “Thanks for reminding me, I will explain my reasons later, can you please move him as fast as you can to the scanner and get a CAT scan of his chest?” They reluctantly followed my order. Within 5 minutes, I got the call from the radiologist. His voice sounded very excited and surprised at the same time. He said, “This patient had a major event. He had a dissection of his aorta extending into his brain arteries.” What that meant in plain English was, “This patient has a tearing of the largest blood vessel that carries blood out from the heart to the rest of the body. The tear is long enough to reach all the way to his brain from his heart.”

Medical diagnosis: Correct and timely diagnosis saves a life

Finally, everything made sense: the sudden collapse, the low blood pressure and even the seizure. I immediately called the cardiovascular surgeon and then went to the patient’s bedside to tell him what we had just discovered. The patient was on the operating table getting his blood vessel repaired within the next 30 minutes. His life was saved.

Aortic dissection was his final medical diagnosis. It is almost always fatal without timely treatment. Every hour after the event, the mortality rate goes up by approximately 10%. Luckily, he arrived at our hospital about 4 hours after the event and was operated on within 5 hours of the event. That meant he still had a 50/50 chance of survival. As you may have guessed, the odds were in his favor that day.

The surgeon was very impressed with my medical diagnosis. Normally, aortic dissection causes pain in the chest and you only think about this medical diagnosis when someone is presenting with a symptom of chest pain. In this case our patient did not have any chest pain at all. It was probably because he almost collapsed before he could feel the pain. As the tear extended all the way to his brain arteries, he collapsed and had some seizure like activity. His blood pressure was low as the blood supply to his whole body was compromised.

They all said I was the one that saved his life. But, that is not true. I was merely putting all the pieces of the puzzle together. If the rural family doctor had not paid attention to his hunch, he would have been dead. If the patient had not been able to tell me how exactly he felt, he would have been dead. If his blood pressure had been normal, the family doctor might not have been alarmed in the first place and he would have ended up dead. If the wife and the son had not individually shared their story with me, I would not have asked the right questions and he would have ended up dead too.

The moral of the story is not how I saved a life but how imperfect our medical system is. If you think about it, how easy it is to overlook a minor detail and how that can result in something catastrophic. It is important for us to get every small detail clarified as much as possible. Normally, patients and their family do not understand how much weight we put on the story they provide us. I will be sharing numerous real patient stories with you  on this website to tell you how we arrive at the right or the wrong medical diagnosis based on what the patients and their family tell us. You can all help your doctor save more lives my sharing these stories with your loved ones so that they understand how doctors make medical diagnosis.

Medical diagnosis: What is wrong with the traditional view of symptoms and diagnosis?

Traditionally, symptoms have always been thought of as items belonging to a disease. In my opinion, this concept is fundamentally wrong and is the main reason why people get wrong medical diagnosis. Symptoms belong to the patients, not to the diseases.  You need to look at the symptoms of an individual patient who is in a unique situation and try to think what changes in the body of that patient could produce those symptoms. When you do that, you will get one step closer to getting the right medical diagnosis. Traditionally, what people do is try to match the symptoms of the patient with known symptoms of a disease from textbooks. This can lead to wrong medical diagnosis as symptoms are very subjective and depends on the unique features of the individual patient. If you really want to make sense of the symptoms, you need to know the patient very well. This is what I want to do in my book project “Symptoms and diagnosis.”

 

Thank you,

Nabin Sapkota, MD