The Case Of The Dilated Pupil
15 Mar 2010
What causes the most problems for patients? Ask Dr.Jerome Groopman, Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston. He’s author of the book "How Doctors Think" which outlines a study of 100 incorrect diagnoses.
Dr. Groupman was interviewed by Dialogue, a publication of The College of Physicians and Surgeons of Ontario. He says that the wrong diagnosis isn’t usually due to the doctors’ ignorance, but by failing to ask the right questions.
For instance, Dr. Groopman relates the story of a 80 year old man who had been seen by four specialists. The man had only one complaint? He said he suffered from "poor stamina". During several months specialists carried out cardiovascular, pulmonary function tests along with an extensive endocrine work-up.
But following this exhaustive study the only finding was a mild decrease in the male hormone, testosterone. This was not shocking as males normally have a decrease in testosterone as they age. But he was, nevertheless, sent to another endocrinologist.
Fortunately, this doctor had been imbuded with a big dose old-fashioned horse sense because he asked the obvious question, "What do you mean by stamina?" The man simply pointed his finger at his legs and said, "I get pain when I walk on the golf course and have no stamina in my legs."
This direct-to-the-point question, then made the diagnosis as simple as 2 plus 2 equals four. He was obviously suffering from intermittent claudication of the legs. Due to a narrowed artery, insufficient oxygenated blood was reaching his leg muscles, causing pain after walking a few steps. Asking the right question would have saved a huge amount of money.
The Harvard Medical Alumni Bulletin cites another situation where questioning is so vital. A young boy had been playing in the room when he suddenly developed a headache and blurred vision.
His parents rushed him to emergency where examination only showed a dilated pupil of his left eye. But it’s not a good sign and could indicate a tumour or an aneurysm of the brain, a terrifying situation for parents.
Parents advised the doctor that their child had always been in good health, had no previous eye injury and did not use eye drops. Eye examination failed to reveal increased pressure or other problems.
The doctor then recalled a patient he had seen years ago, who also had one dilated pupil. This researcher accidentally spilled atropine on his finger, then rubbed his eye. Atropine is extracted from flowering plants and during the Renaissance women would dab a bit of the juice on their eyes to dilate the pupils thinking it made them more attractive.
But parents again stressed their child was not using eye drops. However, it’s an old maxim that if you talk long enough the patient tells you the diagnosis. So the doctor persisted and said, "Are you sure no one is getting eye drops?" Suddenly his mother said, "Oh my God what are we putting in fluffy’s eyes." They had forgotten a veterinarian had prescribed eye drops for the cat. It turned out they contained 1 percent atropine and some of it had been transmitted to the fur and to the boy’s eye. It remained dilated for another seven days.
In another case a young girl developed a headache and began bumping into things. Parents told doctors she was not taking any medicine. Standard tests showed nothing worrisome. But an MRI revealed a strange whiteness of the optic nerves. Then, an ophthalmologist, discovered she was almost blind. Later, a lumbar puncture revealed the pressure in her skull was over two times the normal level. It’s an ominous finding, but nothing could be found to explain her problem.
The family became annoyed at being asked repeatedly if the girl was taking medication. Finally the doctor asked, "What about vitamins?" Her Mother replied, "Does fish oil contain vitamins?" It turned out she had been given the recommended daily adult dose of Smith’s Fish Emulsion. This adult dose had caused vitamin A toxicity.
The moral. Asking the right question can save a ton of money and worry.
