Since medicine is such a relationship based vocation, I find myself very often looking at my patients as people and not as clinical subjects. I have to keep reminding myself to do both.
I saw a cancer survivor recently whom I have known for ten years. I had referred him to a neurologist because of an atypical tremor. The neurologist diagnosed my patient with Parkinson’s disease but also pointed out that he had Horner’s Syndrome (droopy upper eyelid, small pupil and sunken in eye as we describe it in Sweden, lack of sweating on that side of the face, the way Americans describe it).
Was I ever humbled; I had seen the droopy upper right eyelid since I first met the man, but never had reason or, rather, been medically curious enough to check his pupils – the pupil on the droopy lid side is indeed smaller.
I have seen Horner’s Syndrome a few times, twice in the context of sinus cancer. One case was a woman who ended up with surgery that exposed the back of her eye socket and the back wall of her maxillary sinus, just like the pictures in my old anatomy books, the other was my own cat, who did not go through such radical surgery. Both died from their disease.
My Parkinson’s patient must have had the syndrome for a long time and no underlying disease has been found in his case.
I remember during a Harvard endocrinology course I started looking at passing strangers in downtown Boston every afternoon between class and dinner and wondering if they had acromegaly, polycystic ovaries, Klinefelter’s Syndrome, Cushing’s Disease or some other topic discussed that day.
But to be honest, I have dragged my feet many times before ordering the tests to rule such conditions in or out, almost as if I don’t want to insult my patients by suggesting their appearance is pathological.
That just isn’t right. I need to be a keen observer of clinical signs of possibly life altering diagnoses; I need to look at each one my patients not only for any change in their appearance, which I’m pretty good at, but also against my memory files of clinical syndromes that I, as their trusted family physician, should notice before some out of town specialist makes the diagnosis in a single appointment that wasn’t even for that particular abnormality.
Maybe that can be a late New Year’s resolution of sorts.
Nonetheless, your patients are fortunate that you remember them and can compare from visit to visit. I get to see my PCP once a year for 15 minutes and I doubt that she even remembers me from year to year. She mostly orders the normal blood tests, gives the spiel about if I need to have a colonoscopy (done in Dec and told come back in 7 years…maybe…as I’ll be 80 by then and colonoscopies not typically recommended at that age), mammogram (again, I’m now past the age of consent so to speak)…and then I get a note about the results of my blood tests..maybe. Last year my A1C as always, was elevated (daily finger pricking show me to not be pre-diabetic or diabetic), TSH was a little high, lipids close to normal but slightly off and I didn’t hear a peep from her. Perhaps not bad numbers for my age?
I see the cardiologist/electrophysiologist a few days after I see her and I’ll speak with him about maybe changing my going on 20 years metoprolol XR and losartan for a different beta blocker, the one that starts with an N, and try an Ace inhibitor rather than my ARB, only because I have chronic insomnia and restless legs and I finally thought to see if either of my two maintenance drugs prescribed for an ancient afib episode might have any relation and they do! Supposedly the N beta blocker and the L ACE med do not have sleep or restless legs side effects although the ACE might give me a cough. I don’t expect doctors to know all the possible side effects of every drug but I’m kind of surprised that no one has made the possible connection of the meds to my poor sleep and restless legs all these years. And I realize that there may NOT be. I take the lowest dose out there and my body should be used to them now. Still, if a substitution will give me the same heart rate/BP mods and not exacerbate my nighttime issues, I’ll count it as having been well worth trying.
Keep caring the way you do for your patients. They are lucky to have you.
I was a pediatric critical care nurse for 38 years, and retired now for three years. I look at people all the time in Walmart and at church , and it takes everything in me not to go up to them and say something about their pallor, their gait, their tremors etc.