Two skills needed in primary care are tenacity and listening. That is a combination that can make a diagnosis. Here is an example.
In residency, many years ago, I have a patient with developmental delay. He lives in a group home. He can’t talk though makes some noises. The group home staff bring him to me. His head is misshapen because his mother had measles in her pregnancy.
The staff says, “We think his head hurts. He just isn’t behaving right.”
“Did he fall?”
“We don’t think so.”
“Fever? Nasal congestion? Cough?”
“No.”
“How long?”
“Over the last week.”
I do an exam. I really can’t see his tympanic membranes because of his skull shape.
“Maybe he has an ear infection. I can’t see. We’ll try antibiotics, but if he is not improving, bring him back. In five days.”
They bring him back. “He’s no better.”
I get on the phone. I need a CT scan of his head and the group home say he won’t stay still. I need anesthesia to sedate him for the CT scan. It takes two tries and quite a bit of phone explaining with both the anesthesia department and the radiology department. Persistence. I am looking for a subdural bleed in his head from a fall, or a sinus infection, or something.
It is done and I get a call. Not from radiology or anesthesia but from the ear, nose and throat surgical resident. He is very excited. “Your patient!”
“Yes,” I say.
“He has a pseudocyst! In his sinuses! He has abnormally large sinuses and this is the biggest pseudocyst anyone here has ever seen!”
“Um, ok.” Honestly, I’ve never heard of a pseudocyst. It turns out to be packed nasal drainage in the sinus. Bad ones can erode through bone into the brain. Certainly that seems like the cause of the headache!
“We are taking him to surgery!”
Residency can be pretty weird, when someone gets really excited about a rare disease or interesting trauma case or whatever. I found that I was entirely happy just doing health maintenance exams and encouraging people to quit smoking and exercise and drink less. However, I was also good at finding weird things.
The ear, nose and throat surgeons in training were very happy about the surgery. The group home staff were happy too. “He’s back to his old self. Thank you!”
It took tenacity to set up the head CT. It’s important to listen to the families and caregivers too, because they know the person better than I do. They were right: his head hurt. And we found out why and were able to treat it.
For the Ragtag Daily Prompt: tenacity.
Water is tenacious too, wearing down stone and wood and glass.
KO Rural Mad As Hell Blog 
Your story brings to mind Patient M who came in after her previous optometrist had closed down leaving no forwarding contact. Her last visit with them had ended with “you need to have another glaucoma visual field test, as the one we have just done was indeterminate”. We ended up doing 3 visual field exams as M was anxious and finding it very hard to keep her fixation steady. Eventually we coached her to keep her focus on the central target at all costs and this produced a convincing picture of a left homonymous hemianopia. I called her GP and heard a perceptible sigh of relief from her on hearing a possible explanation of her patient’s problems. She booked a scan for M immediately and within days M was undergoing intracranial surgery for meningioma. Busy GPs do not often get time to call or report back to the referring optometrist. However, M herself reported back in due course with a hug and a Thank You card and news that she was playing tennis again.
A feel good day.
That is wonderful!
It was always great when the residents got excited about a case: 1. everybody learned something because their enthusiasm was contagious – they taught!; 2. while occaisionally invasive the patient got ” cadillac” care, and better outcomes in general.
It was true we pulled out more supplies, juggled schedules more, worked longer hours and grumbled. But after a day of three cholecystectomies, a hip replacement and an inguinal hernia it was interesting to do something unique.
At the end of the procedure you had the opportunity to feel real good about the patients prospects. Not to shabby a feeling.
Very true!
Yay for tenacity! Sometimes hoofbeats do mean zebras.
When I had babesiosis, it took 12 hours in the ED and a LOT of bloodwork to find out what was wrong with me. Two residents zeroed in on it at about 3 AM when I noticed the direction their questions turned. Hanging out on a gurney through the night I imagined them sitting around in the resident room tossing darts at the wall to see what would stick, knowing they had to have an answer for their attending because you can’t ignore a fever when it passes 40º C (104º F).
Absolutely! My partner in our small town diagnosed malaria. Someone who had come off a ship in Bremerton.
This is a great story. Tenacity and attention. Absolutely.
When my asthma/breathing problems (sinus) showed up my “doc” threw all kinds of stuff at the asthma and ignored the breathing problems. It just got worse because the CAUSE was also something she prescribed. Low dose aspirin and an NSAID for arthritis. She didn’t say, “This is puzzling. It should be improving. Let’s get you to a specialist.” She said, “Why aren’t you getting better?” She was mad at ME.
After nearly passing out while driving, I hauled myself to an ENT specialist who did a thorough examination of my sinuses and lungs. He had never seen the combination of symptoms before. He sent me to an allergist. She did a total test and found I had no allergies. She was puzzled and had me wait while she did research. About half an hour later she came back, “I think I got it.” She asked me questions and she had gotten it. It was the aspirin and NSAIDs in combination with something in my fundamental physical make-up, an uncommon condition but definitely not unheard of.
Both she and the specialist were really excited by the discovery, but not as excited as I was. Obviously. The ENT specialist was the best doc I’ve ever visited. He saw something on my cheek and sent me to a dermatologist who took out a skin cancer. BUT… Thanks to bad experiences, I’m terrified of doctors. I’m terrified of not being listened to, of being brushed off as “another old lady with complaints.” My BP at the doc goes up absurdly.
I am sorry about the terror and trauma! But so glad the ENT was good!
He was great as was the allergist. I’m grateful every day for those two caring, curious, kind people.