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How many doctors does it take to make a diagnosis?

Janet Webb
BSc(Hons) RGN
DiPN(Lond)
Practice Nurse
Lindum Medical Practice
London

Judy rang one afternoon to ask if I would "have a look" at her husband Bob. The couple live in an old terrace by the canal. Judy is a podiatrist, now practising privately, and Bob was a gardener with the Parks Department, now retired. He's probably about 15 years older than Judy. Their garden is a marvellous perfusion of intermingling flowers and bushes, in old-fashioned cottage-garden style, and it's hard to believe that it's located in a city; it matches Judy and Bob. They're both very slim, and both wear woolly hats, Doc Martens, denim and donkey jackets. We met nearly 20 years ago when Bob was still with the council, and he'd pruned his thumb as well as some roses. Judy taught neuropathy screening on my diabetes course. Bob is a taciturn man – not ignorant, just happy in his own company and comfortable with silence. He's a typical countryman, despite being a city dweller. Over several appointments we became kindred spirits through our love of animals and the countryside. He doesn't think much of modern medicine and doctors, and has no time at all for health promotion. I have immense respect for his knowledge of country lore.

Bob smokes roll-ups and likes to drink whisky; he had been sitting out in his garden watching the sun go down with a bottle of whisky the previous night (he often stays out until around midnight on summer nights watching the bats), after Judy had gone to bed. When he had joined her he'd complained of a pain in the right side of his chest, although said he'd probably stumbled against something in the garden. Judy had told him he was a silly old drunk, only becoming concerned when the pain was still there in the morning. He'd previously broken a couple of ribs on that side in a fall and they'd convinced themselves that he must have got cold sitting outside, and aggravated the old injury, but ... well ... could I just look him over? I invited them to come straight round.  

A couple of weeks earlier, I'd seen a man in his 20s complaining of a central chest pain. I'd invited him straight round as well, and taken his history while doing an electrocardiogram (ECG). He'd fallen asleep at the table the night before while eating a pizza, and woken up with the pain, then not eaten anything for the next 16 hours, which was when I saw him. The ECG was normal, the pain burning in character from epigastrium to throat with an unpleasant taste. I'd diagnosed gastro-oesophageal reflux disease (GORD) and prescribed an antacid. That night, he'd gone to the out-of-hours service, where he had been given antibiotics for a cough, and he had written a complaint, advising me I would be hearing from his solicitor. The doctors reassured me they would have done the same, but my confidence in my judgment and self-esteem was still smarting when I saw the couple.

Bob trailed in behind Judy, downcast and submissive rather than compliant, and I couldn't help thinking how similar he was to a greyhound being taken to the vet (in the nicest possible way). We went back over the history, and Bob stripped his top-half in preparation for a check ECG. I was going to learn from my previous leap to a conclusion, and check him thoroughly. The ECG was perfectly normal, but his blood pressure was raised, at 168/98. His pulse was 92 and regular. He confirmed that he couldn't remember falling, although the whisky had completely disappeared from the bottle so anything was possible, and his numerous cats had stayed up with him, so he could easily have fallen over one of them.

His chest was still sore, but not to the touch, and there was no bruising or obvious deformity, which rather discounted an injury bad enough to still be painful. He had smoked lots of cigarettes and eaten breakfast and lunch, none of which had affected the pain. He denied having a cough, while simultaneously holding his chest and coughing, then qualified this by saying it was just his usual cough.

He said it didn't hurt to cough, but it certainly looked as if it did, and he seemed a little breathless. Judy thought so, too. Bob seemed vague and cagey, although really no more so than when I'd seen him previously. He could have been frightened. His chest movement seemed equal on both sides, but was difficult to judge since his respiration was quite shallow. When I asked him to take a deeper breath, he coughed, which aggravated the pain.

On auscultation I was convinced, however, that the breath sounds were quieter on the right lower lobe, and on percussion there was more resonance on that side. I'm not experienced in examining vocal fremitus – I tried, but could not find any noticeable difference, and vocal resonance was difficult because Bob speaks quite softly. According to Epstein et al, both should be reduced in pneumothorax, although they advise that a decreased percussion note can be difficult to detect.1 Similarly, I'd failed to find reduced expansion on the painful side, but this might have been because his respiration was shallow, due to the pain.2

On previous attempts at chest examination, I'd rarely found anything other than wheeze; this time I was not confident that I'd actually found the abnormalities and wanted to check again, but Bob was obviously in some discomfort, and kept shifting position. I had never actually found a pneumothorax before, but felt that, in theory at least, I was probably looking at one now.

A pneumothorax can occur spontaneously, often in tall, thin males, although it is more likely in the under-40 age group.3 Bob was 75 years old. It can also be secondary to lung disease,4 such as chronic obstructive pulmonary disease (COPD), and Bob was a long-term smoker. If associated with underlying pulmonary disease, the consequences are much more serious and carry a 15% mortality rate,4 and if my suspicion was correct Bob would need urgent treatment to aspirate.

I told him he may need a chest X-ray as I thought I had found an air bubble between his ribs and his lung, and that because the local hospital insists on request forms being completed and signed by doctors I would need to speak to one. I asked if he minded if the doctor also examined him, to be sure of my initial diagnosis. He was still subdued, and agreed without further comment.  

While waiting outside the duty doctor's room, I was joined by our current GP trainee and medical student, both of whom had patients they wanted to discuss. They wanted to examine Bob, as he sounded interesting, and Bob amazingly said, "Oh, the more the merrier" when I consulted him. I continued waiting for the GP, and we joined them all in my room just as the student was expounding about the bilateral wheeze that would most likely mean pneumonia, and the GP trainee was examining Bob's back, saying he had spondylosis, which was possibly the cause of his pain. The GP agreed to the chest X-ray but said Bob had probably had enough of us all for the time being and advised analgesics, a sputum specimen, and a review the next day for a BP check. Judy took him straight to the hospital for the X-ray – they admitted him for insertion of a chest drain after confirming the "large, right-sided pneumothorax, probably secondary to COPD". There was no mention of pneumonia or spondylosis.

Of course, that means Bob will be badgered to stop smoking, we'll have to encourage him to come and see us more often, offer him flu and pneumonia vaccines, all the while respecting his views, without turning him into a "patient". Bob probably won't change his aversion to health promotion, so we'll have to tread carefully; the risk of recurrence for a pneumothorax is about 40%, most occurring within 18 months to two years.4
So how many doctors does it take to make a diagnosis? None – just a practice nurse, as long as the patient hasn't fallen asleep eating a pizza.

References
1. Epstein O, Perkin GD, de Bono DP, Cookson J. Pocket Guide to Clinical Examination. Second Edition. London: Mosby, 1997.
2. Forbes CD, Jackson WF. Color Atlas and Text of Clinical Medicine. Third Edition. Edinburgh: Mosby, 2003.
3. Family Practice Notebook. Simple pneumothorax. Available from: http://www.fpnotebook.com/Lung/ER/SmplPnmthrx.htm
4. MedicineNet.com. Pneumothorax. Available from: http://www.medicinenet.com/pneumothorax/page3.htm

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"What a witty, well written article. It is a clear description of the linked relationship between  diagnosis, self-esteem and confidence to practice." - Judith Roberts