Always start your diagnostic search from the beginning

It is a trade secret among patients of many practices: If you’d like to be seen by your personal physician with no waiting and without an appointment, just ask for a free blood pressure check and then mention to the medical assistant that you are not feeling well at all. They can’t send you home without being seen and they don’t have enough to go on to call an ambulance; you are 99% assured to get seen quickly by the doctor.

Today’s free blood pressure-turned-extensive-visit was a diabetic with a history of a heart attack a dozen years ago. She just didn’t feel right, but otherwise had no specific symptoms. She had no chest pain, heart palpitations, shortness of breath, headache, dizziness, cough, fever, chills, indigestion, belly pain or anything else to report; she just didn’t feel right.

Her exam was normal, except the mildly elevated blood pressure, which was high enough that the first staff member she saw summoned me.

“I’d like to get an EKG to see if it shows any sign of trouble,” I said.

“I knew you would do that,” Mary Anderson (not her real name) said. “I told my son on the phone this morning, ‘I bet it’s my heart. That’s exactly what I said, but I don’t know why I thought that.’”

Her EKG showed new Q-waves in leads III and aVF with T-wave inversions, signs of a heart attack in the lower portion of her heart.

“Mary,” I lectured my patient while we waited for the ambulance, “if you don’t feel right, ask to see me or one of the other doctors. Don’t assume that your blood pressure is the reason you don’t feel well. What if your blood pressure had been normal? Would you just have gone home without getting any help?”

Mary is not one to work the system for quicker access to me. In fact, as much as she may like me, she hates having to come to the clinic for her health issues. She would rather be doing her senior volunteer work than worry about her own health. She asked for a free blood pressure check because she hoped her blood pressure was off and that this was the simple reason why she wasn’t feeling well. Even though she had worried about her heart, as she told Donald, her son fifty miles away, she admitted she had tried to rationalize her deepest fear away.

The lesson for all of us in health care, beginners as well as seasoned health care workers, is to never assume that the chief complaint is the same as the ultimate diagnosis. This is especially true when the patient’s stated concern is high or low blood pressure, blood sugar, potassium or some other quantifiable parameter. People try to help us narrow our search for the explanation to their symptoms. We must never start our search in the middle, but always from the beginning.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • understandnatives

    The author writes, “It is a trade secret among patients of many practices: If you’d like to be seen by your personal physician with no waiting and without an appointment, just ask for a free blood pressure check and then mention to the medical assistant that you are not feeling well at all. They can’t send you home without being seen and they don’t have enough to go on to call an ambulance; you are 99% assured to get seen quickly by the doctor.”

    I am sorry but this strategy works ONLY for white people.

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