Friday, February 8, 2013

Day 237 - symptoms

"You've been waking with nightmares for months? Why didn't you tell me?" I bet almost every clinician has had the experience of asking a patient about a key symptom that they endorse as having been present for months. It can be so frustrating because if you had known they'd had neuropathy or hiccups or whatever, you would have been able to identify their problem sooner. It's really hard not to say "Why didn't you tell me sooner?"
The thing is, however, all of us have a whole list of odd symptoms that are happening at any one period in our lives and if we mentioned all of them, even to a sympathetic and interested doctor that you know will not look bored, you will feel like a hypochondriac. It can be hard to separate the important stuff from the not important stuff if you are not a doctor. And, if you are a doctor, imagine trying to construct a question that will get the patient to tell you that for the past eight or ten years, every few months, they get a few days where they intermittently have the sensation of a piece of yarn wrapped around their big toe and the rest of the time, their feet feel normal that will not also yield half an hour's worth of information you are not interested in.
Alternatively, it can be hard even if you know that your doctor would be interested in some symptom, if they don't ask about it, to offer it. No, I don't have diarrhea, coughing, shortness of breath, fatigue or weight loss, but I do have this weird feeling...
It's not clear to me what, if anything, one could do about this situation. Clearly, you can't ask questions about every potential variety of sensations that a patient might interpret the symptom of interest as. A doctor calls it shortness of breath; the patient feels it as "there is something lacking from my breath, but only when I take a deep breath" and will deny shortness of breath (true story). You can not ask every patient whom you want to know if they have shortness of breath, "do you feel something lacking in your breath?" and then you would also have to ask them "do you sometimes feel some pain above your collarbones?" (additional true story) because you never know how a particular symptom will manifest with a particular patient and you would have to ask them a nearly infinite set of questions on just that one symptom, then move on to orthopnea. I think the best you can do is to make it as comfortable as possible for them to bring you whatever they feel they can and to sort through it as best you can. It's those open ended questions again.
That's what I've been thinking about on this snowy day. That and "Sleepwalk with Me" which was pretty funny.
For me, for tomorrow, I will hope for a pleasant, inside storm day and safe travels for myself and also for you.


  1. Hi Mary,

    good post! Lots that I can relate to on the patient side here.

    "they get a few days where they intermittently have the sensation of a piece of yarn wrapped around their big toe".

    is this a humorous hyperbolic example or a real thing? Inquiring minds want to know, particularly since I first read it as "piece of yam". These old eyes ain't what they used to be. ;^)


    1. Thanks.
      This is actually a real thing that has happened to me. Initially I thought it was probably MS (because that is about the least likely and most catastrophic thing it could be and that is where I always go), but when nothing else consistent with MS developed, I figured it was probably something else. Eventually I decided it was probably a B12 deficiency symptom and then when I got my first set of labs in March, they were consistent with B12 deficiency, too, so I worried less about them than I would have if I hadn't had intermittent neuropathies over the years.
      A really interesting thing is that I know my doctors would be at least a little interested in neuropathy (it is also on the list of side effects from the chemo I got) and it just never seemed appropriate to mention it. No one asked me specifically about it and even though lots of residents and attendings spent lots of time with me, it just never seemed like something to mention.
      It feels stupid to mention it apropos nothing and the conversation never got around to someplace where I felt it would make sense to mention it. I know it's not an important thing--it's mild; it's intermittent--so I haven't felt any imperative to mention it.
      It's really an interesting thing. People will get all kinds of variations on symptoms and specifically deny the official symptom, but agree to some unusual symptom that might be a cousin of the symptom you are looking for. I've made a bunch of diagnoses at various points in patients because I was willing to think "outside the box" when they said they had symptom X, could it really be part of Q or Q filtered through their particular nervous system/cognitive processing of the raw sensation.
      It would be fun to have a list of all the varieties of things that people endorse instead of what we doctors think of as a standard symptom. Hmm. This is the sort of thing that the internet was made for, isn't it?
      I think I will elevate this comment to a post in addition to being here because people might miss it in comments.