Often the patient tells you the diagnosis

Often the patient tells you the diagnosis

Vijay Gopichandran

“Listen to the patient carefully, she is often telling you her diagnosis when she is talking to you”, my teacher Dr. K.P. Misra used to say. When we were in his clinic and undergoing our medical education outside of our medical schools, Sir, as all of us used to lovingly call him, used to drop these pearls of wisdom in the passing. All of us picked up those pearls and strung them together into our lives. Today, most of us are decent clinicians because of him and what he taught us during the 101 (the room number in Apollo Hospital, where Sir practiced cardiology) days. I am narrating two instances where the patient told me the diagnosis during the process of careful and attentive history taking. One of these events happened today and led to this blog and as I was preparing to write this one, I remembered the other incident that happened a few months ago.

Today, towards the close of the clinic, a middle-aged woman in a full black colored burkah walked into my clinic. When I asked her how she was and what brought her to the clinic, she started narrating this story,

“Sir, I was diagnosed to have diabetes 3 years ago. At that time, I was started on diabetes medications. Initially, I was very much worried about my diabetes. But now I am not worried about it anymore. I have got used to living with diabetes. What bothers me most are two major complaints. First, I am suffering from severe constipation, and worse than that, I am having this severe itching and rashes all over my body and it is getting worse by the day. The itching and red colored rashes started soon after I was diagnosed with diabetes. I would go to my doctor, complain about it and ask for help. The doctor would say it is some form of allergy and give me medicines for 3 days for the allergy. For those three days, the itching would reduce and then it would start again. I used to go to the doctor as soon as the rashes came back, and the doctor would prescribe the same anti-allergy tablets every time. I started noticing that the skin started peeling off and falling like powder from my hands and feet. Then I started developing severe rashes and burning sensation in my private parts also. Once I even noticed that the rash reduced when I temporarily stopped taking my diabetes medicines. But flared back up when I resumed my diabetes tablets. I even told this to the doctor. The doctor said it could be an allergy to something and kept giving me the same medicines for allergy. I have been going through this skin problem and suffering since the past 3 years. I want your help. Please help me. I can manage any problem, but this itching is troubling me too much. Sometimes I scratch myself so bad that I bleed from my skin. Once I rubbed my feet against a stone so hard that the skin from my feet peeled off completely. I can’t live with this problem anymore. Please help me.”

I heard this story and took one look at her medication list, which comprised of glibenclamide (sulphonylurea group of anti-diabetic medicine) and metformin, and I knew the diagnosis. This was a typical example of what Sir used to say, “the patient is telling you her diagnosis”. Glibenclamide is a drug which contains sulphonamides and therefore people with allergy to sulphonamide containing drugs will develop a severe form of sulpha allergy to this drug. A typical sulpha allergy presents with rashes all over the body with itching and redness of mucosa including eyes, mouth, and genitalia. The patient herself told us that the symptoms became better when she was off diabetes medications and became worse when she got back on them. An astute clinician would immediately think of a drug-related problem. But this poor woman had been suffering from this potentially curable drug-related problem for 3 years without any help. All that was needed was for some genuinely interested person to fully hear out her story as she told them her diagnosis herself. I stopped her glibenclamide and have started her on steroids for the allergy, under good anti-diabetic cover to prevent the poor control of sugars caused by the steroids. She will soon recover and be able to handle her diabetes in a more empowered manner.

The other instance where the patient herself told us the diagnosis was in case of a mother who brought her 8-year-old son for evaluation of severe anemia. On examination, the boy was so pale, that he looked as white as paper. On testing his hemoglobin, it was less than 4 g/dL which is very low. He had been seen by another pediatrician, who frightened the mother of something very dangerous going on with her son and referred them to the tertiary care pediatric center in Chennai. Before going there, the mother, who was very much worried, had thought of stopping by our center for an opinion. We asked the mother the detailed history. She said,

“On that day my son came back from school and went out to play. After playing when he came home, he was very hungry. So, I made him wash his hands and feet and then gave him rice to eat. He ate too much and said he was feeling too full. After a little while, he said he felt like vomiting. So, he went outside the house and vomited all that he ate. The whole rice came out in the vomit. Immediately following the rice, he vomited a mug full of blood. I saw him vomiting the blood and go scared. So, we immediately went to the doctor. There I told the doctor that he vomited a lot of blood. That doctor immediately ordered a blood test, saw the results and referred us to go to the pediatric specialty center in Chennai.”

Here again, the mother was literally telling us the diagnosis. A child eats a full stomach and vomits. Immediately after the vomiting, the child vomits out blood. This is a classic history of Mallory Weiss tear, in which due to the forceful vomiting, the food pipe gets torn and bleeds immediately after the vomiting. The child was found to be otherwise normal during the routine evaluation in the pediatric tertiary care center, where they went for just ruling out any doubts. Here again, the pediatrician who had seen this mother initially just had to hear her story fully and patiently instead of scaring her unnecessarily.

The history is sometimes just a plain and simple textbook narration of the course of events of illness as in the two cases described above. Sometimes a few details may have to be carefully reconstructed to make sense of the history. Sometimes with a little guidance and probing, the history can be made illuminating. Whatever may be the case, it is very rare for a well-taken history to not contribute to the care of a patient. As we were returning home this evening after yet another interesting day in the clinic, we were discussing how most of the patient came to the clinic to just talk and be heard. The dialogue that the physician has with the patient is sometimes very useful in making a diagnosis as described above and most of the times also does a major job of therapy. The tests, scans, and treatment only contribute a small remaining portion of the treatment. This may not work for accidents, emergencies, or life-threatening illnesses like cancer, but for most common clinical ailments, this seems to be the truth.