Pulling Teeth
Obtaining a concise and accurate medical history is an art, and it often takes a lifetime to master. For the majority of us, we train for it daily in our clinical practice. On most occasions that we successfully arrive at a diagnosis through the history, the feeling is bliss. Rarely, however, it elicits anger.
Several weeks ago while I was on primary call, I was called by the emergency room (ER) attending physician about a woman who had left eye pain. The ER doc had dutifully checked the vision in her eye and found it to be 20/200 while the unaffected eye was 20/20. He added that she complained a sudden loss of vision in that eye as well.
I had just stepped into my apartment right before getting called, around 12:02am. Painful loss of vision is concerning by all means, and I rushed back to the ED while glancing through my Will’s Eye Manual for help.
My patient was a 40-yr old woman comfortably sitting in the exam chair. Her eyes were white, and on first glance, I could not determine which eye was in question. On brief exam, her vision in the left eye was indeed poor, although she did not have an afferent defect or a shallow anterior chamber. The fundus on the left eye was clearly severly myopic compared to that of the other eye. I suspected that she had poor vision in the left eye all along.
I began with more questions (in broken Spanish):
Me: Which eye is the better eye?
Patient: [points to right eye]
Me: Has your vision in your eyes changed in the last year?
Patient: No, but he said my left eye was bad.
Me: Who?
Patient: The doctor
Me: What doctor?
Patient: The doctor on 186th street.
Me: What kind of doctor is he?
Patient: eye doctor
Me: As a child, did you see well out of your left eye?
Patient: No, but the doctor said I don’t see well.
Me: What doctor?
Patient: That doctor. [points out to hallway where the ED physicians work]
…
The dialogue continued for 15 more minutes with uninformative dictum speckled with non-sequiturs. I now envy those folks who specialize in pathology or radiology.