Charles P. Vega, MD: In an era with advanced technological means to address patient concerns but real limits on the amount of time that each provider can spend with patients, it's reasonable to ask whether the clinical history, as we know it, is relevant any more. We are going to discuss this today for this month's Critical Issues in Primary Care.
I'm Chuck Vega, and I'm a clinical professor of family medicine at the University of California at Irvine, where I am also Associate Dean for Diversity and Inclusion.
Today, I'm really delighted to be joined by Dr Fabrizia Faustinella, associate professor of internal medicine at the Baylor College of Medicine. She has led efforts to teach and evaluate the physical exam and history taking for medical students at Baylor, as well as the University of Texas. Fabrizia, it's great to have you on board.
Fabrizia Faustinella, MD, PhD: Thank you very much, Chuck. It's a pleasure.
Dr Vega: I feel like not only is talking to patients the most important key to making a diagnosis, but it also establishes a trust that enlists patients on a plan of care. Better yet, careful listening during a medical interview can help the clinician understand patient beliefs as well as their resources, which are often just as critical to a successful plan of care as the right diagnostic test or treatment plan. Still, we can get so busy in clinical care and perhaps so rooted in going through seemingly the same patient histories again and again, that we become insensitive to small or even large and critical details that affect patient care.
Fabrizia, you have some examples. Can you describe them a little bit?
Case 1: A 72-Year-Old Male
Dr Faustinella: Yes, absolutely. A resident presented to me the case of a 72-year-old Hispanic man who came to the clinic complaining of bilateral knee pain and left-leg weakness. The patient volunteered that his balance was really off and that he had started to trip and fall at home. On physical exam, the resident found crepitus in both knees and decided that the most likely diagnosis was arthritis. Therefore, he suggested ordering a cane and prescribing tramadol.
On further questioning when I entered the room, the patient reported a history of weight loss, decreased appetite, increasing fatigue, and cough for about 3 months. Also, he reported a 50–pack-year smoking history. On physical exam, I found worrisome findings of objective left-leg weakness with obvious motor deficits. At that point, I became very concerned.
On the basis of many red flags—smoking, weight loss, cough, fatigue—I ordered a chest radiograph, which unfortunately showed a very large lung mass. Eventually, further workup revealed the presence of brain lesions consistent with metastasis from small-cell lung cancer, which was later confirmed by the biopsy and workup.
This is a quite interesting case where important elements of the history of the present illness and social history were basically not properly evaluated in the context of the patient's clinical presentation.
Dr Vega: That is a great example and, clearly, a really tragic case. Osteoarthritis should not promote that degree of falling. A lot of times you start with one thing that sets off an alarm, and that opens up a Pandora's box of other symptoms and problems. Sometimes, that can lead you to exactly the right diagnosis instead of a significant delay in diagnosis and management of a serious condition, such as lung cancer.
Case 2: A 55-Year-Old Woman
Dr Faustinella: My next case is in some ways similar. A 55-year-old woman came to our clinic complaining of dizziness, severe headache, nausea, and vomiting. She had been seen in our clinic 1 week earlier with the same symptoms and had received prescriptions for meclizine and antiemetics.
A family member brought the patient back to our clinic by because she was getting worse. On history, she reported that the headache was very severe and very unusual for her—it would keep her up at night. She noticed some twitching in her left leg and left arm that had been going on for 2 or 3 weeks. That concerned me, and I started digging a little bit more into her history.
Unfortunately, she had a history of breast cancer, apparently in remission, but no recent workup was available. Of course, the history of nausea, vomiting, worsening headache, dizziness, in view of the previous past medical history of breast cancer, made me very concerned. I ordered a CT scan, which unfortunately showed a lot of brain lesions. Eventually, we found out it was consistent with recurrent disease.
Dr Vega: One of the things I like to do is ask the patient directly what they think they have. I'm really encouraged by how often they actually know their diagnosis—it's just leading them around to it. When they self-diagnose to some degree, I think their empowerment and adherence to the plan of care is a lot greater because they discovered this for themselves rather than being told.
In cases where you have a patient who has a really big fear of something like cancer, even though the symptoms do not point to that, at least you are going to address that big fear. It's good for patient communication. This does not take a lot of time in clinical practice.
I am also respectful of the fact we have limited time and resources with patients. Your cases were excellent because they demonstrated these windows of opportunity. Paying attention when there is a red flag or something that does not feel right about a case and taking the time to explore it further can be absolutely critical in treating the patient correctly.
Dr Faustinella: I would like to comment on what you said earlier, that sometimes the patients will tell us what is wrong with them. These are really some of the most critical questions that we can ask: What's going on with you? What are you worried about?
By the same token, patients often have concerns that are really excessive and we can provide reassurance. For example, if patients come to my office with left-sided neck pain and seem overly concerned, I ask what they are worried about. "I'm worried this could be a sign of a stroke," they may say. By asking, not only can we be given critical information to proceed in the right direction, but also we have the opportunity to reassure the patient that maybe what they are concerned about is not really what they should be worried about.
Dr Vega: Great point. That gives us all something to work with constructively. I'm definitely going to use some of these techniques in my clinical practice.
Thank you very much, Fabrizia, for your contributions.
Dr Faustinella: Thank you for having me.
Dr Vega: Thank you very much for attending this session of Critical Issues.
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Cite this: Listen Carefully During the Medical Interview - Medscape - Mar 06, 2018.
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