The art of diagnosis: How to hear more than what the patient says

A few years ago, I missed a diagnosis.  I know that’s not earth-shattering, but the stakes are high for a cardiologist.  Ms. A was an 82-year-old woman with chest pain. She underwent a transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.  The pre-procedure coronary angiogram showed no coronary artery disease and the echocardiogram post TAVR was perfect.

However, a few months after the procedure, she reported arm pain.  It was odd, and specific: if she used her arms too much, like folding clothes, they would feel achy and only improved if she rested and drank cold water.  Otherwise, she was as active as her arthritic hips allowed, shuttling her grandchildren to school through Los Angeles traffic and caring for her aging husband.

I reassured her that her pain was not cardiac because her symptoms were not triggered with exertion and relieved by rest, and because she had a normal angiogram just a few months prior.  I suppose the first time she came to see me, that was understandable.  But she came back a few more times over the next few months with worsening symptoms.  Her echocardiogram was normal.  I shrugged, reassured her, and moved on.

Then, her husband passed away, and she presented 4 days later with shortness of breath.  Echocardiogram showed an ejection fraction of 25 percent with apical ballooning consistent with a stress cardiomyopathy. Her minimally elevated troponin fit this picture.  But since stress cardiomyopathy is a diagnosis of exclusion, she underwent coronary angiography.

The angiogram showed that her coronary arteries were perfect, just as they had been 16 months prior — except for a 99 percent ostial left main stenosis that appeared mechanical and related to TAVR placement.  This is a zebra of a diagnosis with just a few case reports in the literature. But I should have known something was amiss, that her vague and atypical symptoms were a sign of something ominous.  I lay awake at night thinking about the ischemia that led to myocardial stunning and a reduced ejection fraction, and the grandkids that she drove to school every day.  Los Angeles freeways are harrowing enough, even if you’re not over 80 with a critical left main coronary artery stenosis.

I missed a rare diagnosis because I focused just on the symptoms and not on the context.  Here are my 5 tips on what to consider, besides what the patient actually says, so maybe this won’t happen to you.

1. Personality. Some patients will report every symptom to you, while others mention nothing unless prodded. This patient fell into the latter category.  I should have realized that it was not in her nature to come back to me for multiple visits after I had already reassured her and I should have delved more deeply into her complaints.  Family members can be a great resource.  Speaking to her daughter after the fact, it turns out her symptoms were absolutely exertional, though the patient for whatever reason did not describe them as such.

2. Location. Most people dislike the emergency department. It’s noisy and chaotic, and you have to wait a really long time to see a doctor. So a patient who doesn’t call their doctor’s office for an appointment, or go to urgent care, but goes to the ED, is really worried.  I take patients more seriously when they show up in the ED.  If a 60-year-old man has burning chest pain after dinner and presents to the ED that night and not to your office a week later, it probably means he needs more than a proton pump inhibitor.

3. Trajectory. Patient stories have a rhythm: symptoms get better, or get worse, or wax and wane. Have the palpitations been going on for 10 years, occurring three nights a week right before bed for a few seconds, triggered mainly by alcohol use with dinner? Probably benign premature beats.  Does the heart race abruptly for minutes accompanied by near-fainting and, over the past week, shortness of breath?  Maybe a re-entrant tachycardia with cardiomyopathy.  We all know that the longer a symptom has been going on for, the less likely it is to be life-threatening.  But the caveat to this is worsening symptoms.  A symptom that progresses should be respected.

4. Trigger. In relation to #3, sometimes a patient has had a symptom forever, but something triggers them to seek medical attention. So, when the trajectory is flat but the patient is concerned, the trigger can offer insight. Was their next-door neighbor with the same symptoms was just diagnosed with cancer? Did a friend prod them to finally seek medical attention?  Or is the symptom now interfering with their activities?  Knowing the trigger may help differentiate between anxiety and something serious.

5. Your state of mind. That’s right: I’m convinced that our skills as physicians are impacted by the kind of day we’re having. Are you running 30 minutes behind, did you forget to drop off your kid’s art project at school, was your paper just rejected on the second try?  Although we all know how to put our game faces on, we can’t control the competing thoughts in our heads. Being aware of this is one way to control it.  So, if you’re about to go into an exam room, and you’re feeling frazzled because you’re running late and there are three other patients standing outside their exam rooms looking inpatient, take a deep breath.  Remember that it might be just one in a long string of visits for you, but for the patient waiting in the exam room, it’s the one visit of their day.

For Ms. A, it’s an all’s well that ends well kind of story.  Her left main stent went in without a hitch.  Her ejection fraction normalized.  She went back to shuttling the grandkids around.  But I still wake up at 2 in the morning and think about this close call, and what I can do to prevent it from happening again.

Michelle M. Kittleson is a cardiologist.

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