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How Do Doctors Solve Medical Mysteries?

How do doctors make a diagnosis when the symptoms aren't obvious? House Call Doctor plays "House" to solve a patient's perplexing condition.

By
Rob Lamberts, MD,
September 26, 2012
Episode #047

Page 1 of 2

Today's article explains how doctors diagnose those patients with unusual symptoms.

Unlike the drama on television with that other doctor who has the word “House” in his name, the patient is on center stage in the exam room, not the doctor. So your participation is key to getting to the bottom of any unusual symptoms you might have. The purpose of this article is to give you insider information on what doctors do when presented with a mystery condition. The next time you're the one with the unusual condition, you'll know what to expect at the doctor's office.

Diagnosis Step 1: The Chief Complaint

The star of today’s show is Frank, a 42 year-old man who comes to the office for a cough.

My first important question is: Why does this person want medical attention? Doctors call this reason for the visit the chief complaint. Sometimes it is easy to figure out why a patient decided to spend the time and money to see the doctor, but other times it isn’t. When patients say “I’m sick” or “I don’t feel right” as their reasons for coming in, my job is to get more specifics.

Our man came in for a cough, but most people with a cough don’t come to see the doctor. In this case, Frank says he came in because he’s had the cough for two months. So in his record, I write his chief complaint as cough x 2 months.

Diagnosis Step 2: The History

The next step is to listen to the patient’s story, or in doctor speak: the history of present illness (or HPI). To be sure I come to an accurate diagnosis, I need to listen to the story Frank tells without jumping to conclusions. I need to gather as much data as possible before taking the next step.

But not all patients are good storytellers, so there are a series of questions doctors ask to try and elicit the information they need:

  • When did the symptom start?

  • Has it been continuous or intermittent?

  • If it is intermittent, how often does it happen and is there any time of day it is likely to happen?

  • How bad is it?

  • What is the character of the symptoms?

  • Does anything make it get better or worse?

  • Have you taken any medications for it?

  • Have you ever had symptoms like it before?

When the doctor asks these questions, he or she is listening for a pattern. Pattern recognition is one of the most important ways to figure out the cause of mystery symptoms. Be ready to answer these questions when you go to the doctor and answer them as accurately as possible. Really think about the question because the doctor can not properly diagnose you without your help.

In this case, Frank has continuously coughed for the past two months. The cough hasn’t been terrible; it’s just a really annoying dry cough that won’t go away. He’s tried over-the-counter cough drops, but they don’t seem to help. He’s never had symptoms like it before.

Diagnosis Step 3: The Review of Systems

Pattern recognition is one of the most important ways to figure out the cause of mystery symptoms.

The next step, the review of systems, is when the doctor looks for important symptoms associated with the problem. I’ll ask Frank questions related to the other parts of his body, from general symptoms like fever and fatigue, to symptoms related to specific body parts, such as nasal congestion, earache, abdominal pain, and joint pains. It may seem crazy to ask questions about your eyes when you are there for joint pain, but there are many occasions when the answers to these questions end up being helpful.

Frank is not having fever, shortness of breath, nasal congestion, sore throat, or wheezing, but he is having occasional heartburn.

Diagnosis Step 4: Other Histories

Next the doctor looks at any other important facts about the patient. There are three main areas doctors consider:

The past medical history - which includes any medical conditions, past or present, the person has, and what medications they are taking.

The social history - which covers their work and home situations, hobbies, and their personal habits, such as smoking, drinking, and exercise.

The family history - which covers significant conditions that run in the family, like cancer, heart disease, and other conditions.

In this case, Frank has high blood pressure and is taking a medication for it. He’s also had problems with esophageal reflux, which got better when he lost weight. He hasn’t had asthma or allergies. Frank is a firefighter, has a pet parakeet, and doesn’t smoke. His family history is negative for asthma.

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