Wednesday, February 16, 2011

When you hear hoofbeats, sometimes it IS a zebra!

From Dr. Robert Levy

There's an old saying in medicine and healthcare: "If you hear hoofbeats, think horses, not zebras." What that means, is that when you listen to a patient's symptoms and complaints, you should think of the most obvious and common things it could be, and not the unusual or rare things that it could be.

But yesterday, I saw a zebra!

I had a 94-year-old patient who one week ago presented to the emergency room with a complaint of an extremely painful right eye. The emergency room doctor told her she probably got soap in her eye, and flushed it out, and recommended that she see an eye doctor the next day, and gave her the name of a well-regarded opthalmologist in her area. She went to that doctor the next day, still in pain, and he diagnosed a corneal erosion; the sloughing off of the top layer of the cornea. He bandaged the cornea with a bandage contact lens, gave her several drops to use (lubricants for comfort, and an antibiotic to prevent infection) and saw her back the next day. He told her she was significantly better the next day, and scheduled a follow-up for one week later. She came to see me two days before that scheduled one-week follow up, still in pain. I took a look at her cornea, and it was clean as a whistle! No sign of any abrasion or erosion, and nothing visibly wrong with the eye. But she was in so much pain she was literally crying. Further probing of her symptoms revealed that her teeth and jaws hurt when she ate, or chewed, or brushed her teeth, and she had pain in her forehead, and radiating back to her ear. At this point, I knew it was more than just her eye, and diagnosed trigeminal neuralgia.

The trigeminal nerves are one of the twelve pairs of cranial nerves that leave the brain and go directly to parts of the body; this one is called the "trigeminal nerve" because it has three branches - one that goes to the eye, one that goes to the upper jaw, and one that goes to the lower jaw. When she related her eating, chewing, and brushing complaints, I knew it had to be that. "Neuralgia" means nerve pain, and that is what she had. I referred her to a neurologist who will be able to treat her symptoms and finally give her some relief.

So the point of this story is not to pat myself on the back for coming up with a less-than-usual diagnosis, but to advise people to tell doctors ALL your symptoms, even if you don't think they're relevant. If she had mentioned the jaw and teeth involvement a week ago at the ER, or the next day in the corneal specialist's office, they may have been able to come up with the same diagnosis as well. But because she was going to "an eye doctor", she didn't think the teeth and jaw symptoms were important, and she only brought up the eye pain.

Today's optometrists are trained to diagnose far more than eye problems, as long as there is some ocular involvement that brings the patient into our office to begin with!

I look forward to receiving the neurologist's report, and to seeing the patient back when the neurologist discharges her, hopefully finally free of pain!

1 comment:

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