During my first year of medical school, a professor in my clinical skills course shared a timeless adage in medicine: “If you listen closely enough to the patient, they will tell you the diagnosis.” I accepted this statement as a fact of medicine – if I could develop astute history taking skills in my first year, this skill would serve me well throughout my medical training. However, when I volunteered at my school’s free clinic, this statement was challenged by a friendly Latino construction worker, spending his day off at the clinic. Even though he had been waiting in the exam room for at least thirty minutes, he greeted us with a genuine smile and broken English.
Mr. L.’s chief complaint was ankle pain. Before entering the room, I mentally reviewed my plan for the physical exam: gait assessment, neurological exam, and a peripheral vascular exam. I knocked on the door and greeted a friendly man who seemed to be uncomfortable. He complained of pain in his right ankle. I began taking his vitals – pulse, respiratory rate, blood pressure. I noted that his diastolic pressure was high, but I attributed that to medical student error. To be sure, I grabbed an automatic blood pressure cuff from the hallway and checked that it was the proper sized cuff. Mr. L.’s diastolic pressure was still elevated, but I attributed that to the fact that it was my first time using the device. Next, I began my history taking. Ten minutes had already passed, and I had not yet begun the physical exam. I asked him to walk; I checked his active and passive range of motion for ankle flexion, extension, and internal and external rotation. I checked his reflexes, looked for points of tenderness, did a monofilament test, and checked the pulses around his ankles. I noticed he seemed a bit sweaty, which he blamed on the temperature in the room. I asked if there was anything else he wanted to discuss, and he mentioned that he stopped taking his blood pressure medication due to the headaches it was causing. I made a note to mention this to the physician supervising us in the clinic. I thanked Mr. L. and assured him that the doctor would see him shortly.
We returned to the conference room bustling with medical students and documented our findings in the electronic health record. The physician supervising us (Dr. M.) was still busy, so we did not rush to report our findings to her. Suddenly she came to the room and asked who was seeing Mr. L. I raised my hand, and she responded, “When a patient has a blood pressure that’s this high, you need to let me know right away.”
We rushed to her office, and I started reporting on my findings from the physical exam. I began reading the degrees of his ankle flexion and extension, but I quickly realized that was not the chief complaint we were worried about. Dr. M. hurried into the patient’s room and manually took his blood pressure again. For Mr. L.’s well-being, I was hoping that his diastolic pressure had dropped to a normal level. It was common for blood pressure to change with time, body position, or even be elevated solely because the patient was at the doctors’ office (white coat hypertension). And of course, I did not want to have caused a commotion over an inaccurate blood pressure measurement.
Dr. M. obtained the same blood pressure reading that I did. She did not even spend a minute on his ankle because it was his elevated blood pressure, which was the urgent matter. She was concerned she would have to send him to the emergency room if she could not control it and bring it down. She sent him to another room for an electrocardiogram (EKG) to assess his heart function and told him to bring his family into the exam room with him. His wife looked nervous, while his five-year-old daughter brought her Barbie doll along for the adventure. I watched the third and fourth years carefully place the EKG leads. Dr. Marks quickly read the EKG report and was relieved that it was unremarkable. She gave Mr. L a small purple pill (clonidine), and after thirty minutes, we rechecked his pressure, which was thankfully now approaching normal. He was asymptomatic for chest pain and palpitations or other cardiac signs or symptoms. We prescribed him a different medication to take for his blood pressure and requested that he schedule a follow-up appointment to recheck it.
Upon returning to the conference room, I could finally exhale. I suppose having perfectly healthy patients during my standardized patient encounters at medical school did not prepare me to recognize an urgent situation when I was in one. I updated the other students around me that Mr. L was okay and reflected on how this would be a memorable learning experience for me – what a patient wants or complains of is not always what he/she needs. We must see the whole person and get the whole story in order to provide proper care. I also reflected on the calm demeanor of the supervising physician – she did not spend a minute expressing frustration at my mistake, but instead explained what we needed to do next.
Moral of the story: the patient may have a chief complaint, but that might not be the major issue that could kill him/her. Obtaining a complete history and in Mr. L.’s case, finding out that he stopped his blood pressure medication was a crucial point. That old adage “If you listen closely enough to the patient, they will tell you the diagnosis” once again proves true. A patient can show up at the clinic wanting treatment for a rash but could be having a heart attack in front of your eyes. Identifying these urgent clinical situations even when the patient has different priorities is one aspect of the art of medicine that I hope to master.
The author would like to thank Drs. Bryan Bordeaux, Phyllis Nsiah-Kumi, Ishani Ganguli, Thomas Chan, and Sonia Rivera-Martinez for their mentorship and for reviewing this article.
Srijesa Khasnabish is a medical student.
Image credit: Shutterstock.com
