BY HANS DUWEFELT
I have written many times about how I made a better diagnosis than the doctor who saw my patient in the emergency room. It doesn’t mean I’m smarter or even that I have a better average lottery. I don’t know how often it’s the other way around, but I do know that sometimes I’m wrong about what’s causing my patient’s symptoms.
We all work under certain pressures, from overbooked clinic schedules to overcrowded emergency room waiting rooms, from “poor historians” (patients who can’t describe their symptoms or their schedule very well) to our mental fatigue after working long hours.
My purpose in writing about these cases is to show how the disease, which in clinical practice, if you will, the enemy, can present itself and develop in such a way that it can fool any of us. We simply cannot assess every symptom in its entirety. This will clog up the “system” and leave many patients without care. So we formulate the most reasonable diagnosis and treatment plan we can, and tell the patient or their caregiver that they will need follow-up, especially if symptoms change or worsen.
Martha is an intellectually disabled group home resident who has experienced dramatic changes in her behavior and self-care skills. He even seemed a little disheartened. A large examination in the emergency room could only show one abnormality. a CT scan of his head showed a massive sinus infection. He was put on antibiotics and started a ten day course of antibiotics.
A month later, his condition worsened again. It was a weekend. This time he had a slight cough. His chest X-ray showed bilateral pneumonia. He went back on antibiotics and started to feel better.
When I saw him back he was still coughing a bit and he wasn’t his usual happy self. His lungs were clear. I asked his caregiver if they did a head CT the last time he was in the ER. I saw no mention of it in the ER report.
“I’m pretty sure they did,” he said.
I took it from the state’s Maine Health InfoNet website. It described all the sinuses as infected and only slightly improved from the earlier examination.
Martha is now on a longer course of antibiotics because sinusitis often takes much longer to clear than most pneumonia. I sometimes compare it to scooping the contents of an egg through a small hole in the shell (I never learned how to do that). And sinusitis can sometimes cause pneumonia due to postnasal drip.
I saw another case the other day where I think I was able to piece things together.
Gretchen had seen another provider for headaches. She had migraines when she was young, but they stopped after having her first child. My colleague ordered a brain MRI to make sure nothing more malignant was going on. It showed what the radiologist described as possible migraine angiopathy.
By the time I ended up seeing him, he had had a migraine for over a week and was taking daily doses of over the counter medication, so I figured he now had an element of a withdrawal headache. I usually prescribe prednisone in cases like this, but Gretchen told me she had severe psychiatric side effects from steroids in the past.
I asked her to go off the OTC meds and started her on topiramate. Gradually her headaches got better. Then, a few days later, we got a call that his migraines were back with a vengeance. It was already late and he was vomiting. He went to the ER and was given IV fluids, metoclopramide and something for the pain.
I saw him in follow-up and he was better, but very alarmed, told me that his headache had begun to increase again.
Then he told me something that jolted my brain into action.
“When I start having pain on the side of my nose where I had surgery, the headache comes on.”
“What surgery?” I asked.
“I removed a large cyst, I think it was called.”
“Can you take off your mask?” I asked. I had never seen his open face before.
He did and there was a big scar.
“What pain do you have there?” I asked. Is it stable or, for example, pulsatile?
“It’s like stings and stings, like someone’s sticking needles in there.”
I took the monofilament out of my pocket and began touching him over the three branches of the trigeminal nerve on each side of his face.
“Does this feel the same on both sides of your face?”
“No, that’s different.”
I took a deep breath and explained.
“This looks like nerve pain, neuralgia, in the nerve that reaches the skin outside your sinus there, as well as the other two branches that go to the forehead and jaw. It is called the trigeminal nerve and comes directly from the brain. I wonder if that’s why your migraines have returned after all these years.”
“Can you stop it from falling completely?” he asked.
“I probably can’t stop the neuralgia too soon. Most neuralgia meds take a while to start working, but I will send a prescription for Imitrex. Pick one up when you get home and you can pick up another one later today if needed. Then call me tomorrow and let me know how you’re doing.”
The next day he told me that after only one Imtrex he had no headache and the neuralgia was barely noticeable.
I’m curious how he’ll do in the long run, and I wonder if the trigeminal neuralgia has anything to do with the surgery he had there.
As I’ve said before, curiosity is a powerful antidote to burnout.
Hans Duwefelt is a clinician, writer and author of The Country Doctor Writes.