Nailing the Diagnosis, Failing the Patient

Andy was new to me. He told me he had seen several doctors over the past few years for various pains in his right arm.

Some months ago, he had right shoulder pain that went away on its own, but for the past few weeks, he had pain in the middle of his upper arm. Last year he had tennis elbow and forearm pain for many months.

A slender, middle aged man, he had no unusual hobbies and denied injuries or neck symptoms. He was visibly uncomfortable as we talked and kept his left hand tightly gripping his right upper arm, held close to his chest.

He had full movement of his neck and normal sensation to touch of both arms and hands. His intrinsic hand muscles were not atrophied. In fact, his grip was stronger than mine.

I asked him to abduct his shoulder forward and to the side, which he did without pain, even when I resisted his movements – a sign of an intact rotator cuff.

When I asked him to place his right arm over his head, he volunteered that he sometimes slept with his arm in that position as it offered some relief from his otherwise unrelenting pain.

I excused myself with the words “let me get my wiring diagram”. Returning with my tattered paperback copy of Mumenthaler’s pocket neurology textbook from the early seventies, I showed him its picture of the cervical dermatomes.

“You have a pinched nerve in your neck, the fifth cervical nerve, and some of the pains you’ve had before sound like they could have been from the sixth nerve also”, I told him.

His eyes widened. “You know, I did fracture my C-5 twenty seven years ago in a skiing accident, but I’ve never had any issues with my neck since that year”, he said.

We talked about what his options were. Because the pains had come and gone before and had only been severe for a relatively short time, and because his muscle strength was intact, I explained that a short course of steroids might help, at least in the short run. I also offered him pain medication.

“I’ll take the steroids but I’ll pass on the pain relievers. I hate the idea of taking those things”, he said emphatically.

I went over the dosing and side effects of the prednisone and said “if ten days of this doesn’t help, I would go ahead with an MRI”. He nodded agreement and we set up a follow up appointment eleven days later.

Day ten was a Monday. Among the weekend faxes from the hospital that landed on my desk that morning were two emergency room reports about Andy.

The first report, from late Friday night, told of how his pain had escalated steadily since he saw me. They had done plain X-Rays, which showed bone spurs and narrowed disk spaces from C-4 to C-6. They gave him some 5 milligram Percocet, which helped his pain, and sent him home with a prescription for 10 milligrams every 4-6 hours as needed and instructions to keep his follow up appointment with me.

The second ER visit, eighteen hours later, was for nausea and vomiting. The five milligram tablet Andy took in the ER Friday night was just right, but the ten milligram tablets, which he had dutifully taken every four hours, were too strong.

“Did you try breaking the pills in half?” I asked when I saw him back in the office.

“I guess I could have, but I didn’t really think of it”, Andy answered.

“I feel terrible that you ended up going to the ER twice”, I confessed, “because I should have told you that if the prednisone hadn’t done anything after three or four days, it probably wouldn’t work at all. If I had, you would have known before the weekend that you needed to let me know.”

“Ah, that’s all right”, Andy said, but I kept thinking about how the most accurate or clever diagnosis is of little use to a suffering or fearful patient if you aren’t clear enough about what seems like a straightforward plan to you, but not to a patient who never had the experience of being sick or taking medications before. As doctors we assume all patients will make the necessary judgement calls on their own.

I failed Andy and the first emergency room doctor failed him, too. We rattled off our standard instructions without making sure he understood what to do if our treatment plan didn’t work.

That’s the Art that sometimes gets lost in this business.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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