A good doctor will treat the presenting complaint, but an excellent doctor will not only be able to treat the presenting complaint, but also other issues not obviously apparent. Sometimes, this takes observation and clinical experience to see.
I had the pleasure of seeing this in action the other day with a patient that presented with a sudden onset confusion, and feeling cold. When I was taking the history, I noticed that she spoke sentences very rapidly with very quick pauses between sentences. To me, it looked like she was anxious, that’s why she was speaking so quickly.
Examination revealed crackles bilaterally of the lower lobes of her lungs, and an X-ray showed she had pneumonia. The confusion and feeling cold were probably a result of the pneumonia she had. Her urine tested clear.
On review with my senior doctor, he noted that her rapid sentences were no because she was anxious, but probably due to shortness of breath. On questioning if she had previous DVT, she mentioned that she had a previous DVT following a knee replacement. So, what I had just initially thought was some anxiousness, turned out to be a possible shortness of breath (SOB) from a possible pulmonary embolism (PE – a clot in the lungs).
We gave her a shot of clexane (blood thinners) and referred her to her private hospital.
In essence, observing some vital clues may lead to an alteration of management strategies, in this case, a possible PE. Although I would have liked to know whether the patient did in fact have a PE from further investigations, ED is not a place where you get follow up of patients, so unfortunately, I have no idea.