Any primary care clinic has a schedule that lists the appointments of the day in incremental time slots.   There is a column for the name of the patient, the patient’s age, and always there is a place for the reason for the visit–the “chief complaint” according to medical parlance.

A quick review of the “chief complaints” for the day gives the physician a sense of how clinic will flow.   There are the seemingly “quick” concerns, like a blood pressure check, sore throat or ankle sprain, and then there are those that will predictably take longer such as fatigue, trouble sleeping, back pain, or headache.

All health care providers are aware that the chief complaint may not be what the patient really wants to talk about.   Finding out the real concern can be part of the detective work the physician must do.  Sometimes it doesn’t actually reveal itself until the physician’s hand is on the door knob, ready to say goodbye and move on to the next patient.

So I can’t depend on a seemingly routine and straight forward chief complaint to be what it appears on the daily schedule.   When I knock on the exam room door, I need to expect the unexpected.  Otherwise,  I’ll have failed my patient and not done what I’m trained to do–look for what is “beneath” the chief complaint.

Examples:

“itching” in a patient who reports 2-3 months of daily itching, worse at night, with no other symptoms and no apparent rash.  Treatment for scabies showed no benefit, there has been no significant relief from antihistamines or topical corticosteroids.   Examination is unremarkable with no skin findings other than the excoriations from scratching.  Lab work reveals mildly elevated liver function tests.  Additional labs reveal no acute or chronic infectious hepatitis but further work up confirms primary sclerosing cholangitis.

“back pain” in a patient who had been seen with similar low back pain six months previously, but it has been intermittent up until a week prior to this visit when the patient’s legs feel heavy when going up stairs.  Exam reveals an abnormally “stiff” gait but no leg swelling or neurologic abnormality.  Sed rate is elevated and subsequent MRI scan shows bilateral iliac thrombosis due to a congenitally absent inferior vena cava.

“memory lapses” in a patient who notes two weeks of feeling that it was a struggle to remember something that had happened only a few moments before.  Significant recent stress with fatigue but mental status exam and physical exam appears entirely normal.  Screening lab work reveals a significantly elevated calcium, with subsequent testing showing hyperparathyroidism.  Surgery to remove the offending parathyroid gland reveals incidental papillary thyroid cancer as well.

“constipation” in a patient who has noticed bloating in her lower abdomen for several weeks.  She has had normal cycles on birth control pills, has a negative pregnancy test, and a rock hard 18 week size mass in the pelvis.  Subsequent surgery reveals a rare non-metastasized ovarian malignancy requiring aggressive chemotherapy.

“fatigue” in a patient who is puzzled about having slept for almost 20 hours straight.   General disheveled malnourished appearance and smell suggests difficulty with being able to do basic self care and an examination reveals needle tracks on both arms.  Admits to daily heroin use but doesn’t think it is connected to the excessive sleep need since drug use has not changed over several years.

“fever” with headache, myalgias, and nausea for two days in a patient whose rapid strep and influenza screen is negative, lab showing normal white count with a left shift.  Blood cultures eventually grow strep viridans from subacute bacterial endocarditis on a previously undiagnosed bicuspid aortic valve, presumably from a dental cleaning a few weeks before.

“rib pain” in the left lower anterolateral chest wall of a patient with a week of dry cough, congestion, and low grade fevers.  Vital signs and pulse oximeter readings are normal, as well as a plain chest xray, a urinalysis shows some red blood cells. Scan of the abdomen rules out kidney stone but suggests a subtle infiltrate in the left lower lobe.  D-dimer is mildly elevated and scan of the chest shows multiple infarcts most likely related to use of combination oral contraceptives.

Any of these routine “chief complaints” could have led me to conclude an every day diagnosis, forming a treatment plan based on standardized clinical guidelines with prediction of an uncomplicated recovery.   But complacency in a primary care setting would be disastrous.

My job is to peel down through the layers and find what lies beneath the symptom that was the patient’s reason for seeking help.   It is that every day mystery that keeps me coming back, day after day, wanting to know what will happen next when I open the exam room door.

Emily Gibson is a family physician who blogs at Barnstorming.

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