Island Med Student

“If you listen to your patient, they will tell you their diagnosis.” – Sir William Osler

An 89-year old female presents to the emergency department. This morning, she was talking on the phone to her daughter, when suddenly she began experiencing difficulty speaking. One side of her body became numb and weak. Her daughter called an ambulance, and she was brought into the hospital. By the time you saw the patient, she was unable to walk and had lost almost all strength on one side of her body. The patient had no history of any recent traumas. You follow standard stroke protocol, and obtain a head CT.

The results of the CT come back: there are no signs of a stroke, but there is a small subdural hemorrhage. The neurosurgeon wants to perform a craniotomy to correct the hemorrhage. But there’s just one problem. The patient’s clinical findings strongly suggest a stroke, and don’t fit with the diagnosis of a subdural hemorrhage. It’s also possible that although there appeared to be no stroke on the CT, that it’s not yet visualizable, or it was very small and missed. The small subdural could be an incidental finding. It might be asymptomatic. In addition, the woman is very old, and she has multiple comorbidities. She is a high-risk surgical candidate.

So, what do you do? If you choose to operate, she could die on the table. Not only that, but the operation might not even alleviate her symptoms. Surgery also comes with many other risks, including infection. But what if you don’t operate? Might your patient become permanently paralyzed? What will her quality of life be? What if you could have significantly helped her by performing the surgery?

This scenario is actually similar to one that I experienced recently during my neurology rotation. The question became, do we trust our clinical findings and history, or do we believe the CT? It’s a tough call to make. This experience helped me learn a lot about clinical decision making. In the first two years of med school, we learn a lot about various pathologies, and even how to diagnose them. However, patients are presented to us “classically.” That is, they fit into neat little diagnostic packages. The appendicitis patient is tied with a “right lower quadrant pain” bow. The myasthenia gravis patient is wrapped in a “ptosis and difficulty swallowing” wrapping paper.

Then, when you make it onto the wards, you suddenly realize that you almost never get the “perfect patient.” They will rarely present with all of the symptoms you memorized and learned. And even more frustrating is the fact that they might present with “extra” symptoms that can’t be explained by your diagnosis. And as in the case described above, their symptoms and laboratory or imaging results might be at odds with each other. All of this can be a little exasperating, especially since you spend so much time learning how things “should be.”

As I mentioned in my last post, I think the third-year of med school can be a challenging time, and this disconnect between what we learn the first two years and what we see the second two years seems to only add to the frustration. However, I am trying to adjust to the “real world” and take everything in stride. To use the words of one of the astute commenters on my last post, I will continue doing my best to “adapt the disembodied knowledge of the basic sciences to the complexities of a human being telling you a story, and translate that story into a diagnosis and treatment.”

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