Think outside of the box

Another Monday, another new week! Today I was working in the General Respirology clinic, which I initially thought was going to be a repetitive day of asthma/COPD patients. Surprisingly, I saw everything BUT the ordinary! I had a memorable case, which questioned a long-standing diagnosis because my preceptor challenged me to think outside of the box.

I had the pleasure of seeing an elderly gentleman with a 20+ year history of “asthma” who was accompanied by his family to get a “fourth opinion”. He was diagnosed with asthma in the early 90s and had been in and out of hospitals for more than 20 times due to “atypical asthma attacks”. Despite trying many different asthma medications, he continued to struggle with symptoms. He had been referred to specialists in the past who hadn’t made any significant difference in his care. Today’s appointment was his third Respirology consultation. I could sense both the patient and his family were quite disheartened at this point. Based on his history, he had never really responded to bronchodilators. Although there were findings suggestive of an underlying immunologic component to his illness, this alone didn’t explain the severity or frequency of his attacks. Even PFTs didn’t exhibit the classic reactive-obstructive airway. There had been some speculation about his underlying condition is a result of his tracheal anatomy or vocal cord dysfunction, but those ideas were never seriously explored. Finally, the patient also had a history of GERD and UPPP that left him with some swallowing difficulty.

Instead of tackling this patient’s individual medical concerns and trying to find out one explanation for his atypical asthma, my preceptor considered the entire clinical picture and lay out the pieces separately. First, my preceptor told the patient that asthma was unlikely based on the clinical picture. However, his episodes of dyspnea might be a combination of vocal cord dysfunction exacerbated by his GERD as well as UPPP-dysphagia. Based on this explanation, my preceptor referred him to an ENT specialist with a particular interest in studying vocal cord dysfunction. Both the patient and family were extremely satisfied with the certainty and clarity of my preceptor’s explanation. They were grateful that after struggling with a questionable diagnosis for more than three decades, someone was finally offering to look at an old problem with a new perspective.

When we often think of specialists, we believe that they have their specific set of knowledge and are only able to address issues within their scope of expertise. My preceptor showed me today that eliciting and making sense of a patient’s history is not just a job for the generalist. Regardless of where our niche is in a healthcare system, it’s crucial that we consider patients as a whole to help us reach the correct diagnosis.
-AX