When I was teaching in Monash, I always tell my students that taking a GOOD history and physical examination is the key to making a good diagnosis. Some students felt that my history taking is too deep and not worth doing it. I have proven them wrong at many instances during bedside teaching and they will always look surprised and shocked when I come to a diagnosis just from the history without even looking at the patient!
Yesterday, I had an interesting patient who came to see me. This 47-year-old Engineer was seen in the A&E department of a very famous general hospital a day earlier. He was discharged as another case of “giddiness” and was asked to go to the general Outpatient Department the next day. I attach the referral letter here:
The first thing that striked me when I saw this young patient is when he was wheeled into my room on a wheel chair! Why a young 47-year-old need to use a wheel chair ? When I took the history from the patient, I notice something is not right. He stopped working as an engineer in Singapore 2 years ago and since then has been doing some small time business in town. Last 2 -4 months, he has stopped working all together, so much so that he has gone bankrupt, he had to sell his house and currently staying in a low-budget hotel with his wife!!. He has no children. When I asked him why he stopped working, he answer was ” feel tired/weak and no mood?” The family members who accompanied him said that over the last few months, he was seen to be very quiet, keeps to himself and mentally very slow.
In fact, the family came in requesting for a scan!!. On examination, I noticed that he was unable to walk properly, his gait was unsteady. He could not even climb up the couch by himself. Power of the lower limb was reduced to about 3-4/5. Mentally he was slow in response. He did look depressed as well.
Surprisingly, in the letter of referral to OPD , it is stated that ” no neurological deficit” . Any one would have noticed that this guy is NOT well. If not an organic disease, atleast he has major depression. Even if they have referred to a psychiatry clinic, it is still excusable.
I proceeded to do an MRI of the Brain:
What’s the DIAGNOSIS????
A huge Mass over the upper part of Midbrain causing Obstructive Bilateral Hydrocephalus………………………….
As I said, a good history taking and asking yourself “WHY” is the best way to solve a problem.
Ironically, I had to refer this patient to the same hospital again for neurosurgical intervention