Empathy as a Diagnostic Tool in a 33-Year-Old Man with Eye Pain and Vision Loss: Exercises in Clinical Reasoning
J Gen Intern Med
CLINICAL PRACTICE Exercises in Clinical Reasoning Empathy as a Diagnostic Tool in a 33-Year-Old Man with Eye Pain and Vision Loss: Exercises in Clinical Reasoning
Reaford Blackburn
Carlos A. Estrada
David McCollum
0 The University of Alabama at Birmingham , Birmingham, AL , USA
1 Birmingham Veterans Affairs Medical Center , Birmingham, AL , USA
2 Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham , Birmingham, AL , USA
I diagnostic approach (regular text) to sequentially presented n this series, a clinician extemporaneously discusses the clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.
clinical reasoning; empathy; uveitis; syphilis; HIV infection
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Clinical Information. A 33-year-old African-American
man presents with 2 weeks of progressive left eye pain
and vision loss without preceding trauma. The pain is
severe, sharp, and constant. He sought medical attention
when he could no longer distinguish light or movement
with his left eye.
The first thought that comes to mind in an elderly person
with unilateral progressive subacute eye pain and vision loss is
glaucoma. However, because he is not elderly, acute glaucoma
is less likely. Rarely, a young person can present with
glaucoma due to uveitis. For an object to be "visible" in our brains, it
has to travel through several layers: cornea, anterior chamber,
lens, posterior chamber, vitreous body, retina, optic nerve,
optic radiation, and visual cortex. With unilateral pain and
vision loss, the problem originates within the eye or the optic
nerve (up to the chiasm).
Starting with the cornea, a foreign body with superimposed
infection or herpes keratitis can present with severe pain and
progressive vision loss, although near blindness would be
unusual. I would ask about his occupation or hobbies involving
potential foreign bodies. For example, construction workers
are at risk for wood and metal fragments becoming embedded
in the cornea. With a foreign body, blinking will typically
worsen the pain. Moving to the anterior and posterior
chambers, I would consider uveitis. Because sarcoidosis is more
prevalent in African-American patients in the USA, I would
ask about other findings such as arthritis, shortness of breath,
skin abnormalities, and diplopia. Reactive arthritis is also
associated with ocular and skin manifestations including balanitis
circinata (circumferential annular dermatitis of the glans penis)
or keratoderma blennorrhagica (psoriasiform lesions of the
palms and soles). Moving to the lens, I cannot think of anything
that would present like this. Finally, we should consider diseases
of the vitreous body, or endophthalmitis. Fungal
endophthalmitis may occur in patients who have received parenteral nutrition
via central venous catheterization. Progressive outer retinal
necrosis due to herpes zoster infection can cause retinal
detachment and bleeding into the vitreous body.
My next step would be to focus on trying to identify the
anatomical location of the problem: cornea, anterior or
posterior chamber, or vitreous/retina. A detailed physical
examination will be essential, particularly of the eye.
Diagnostic reasoning is often divided into type 1 (intuitive)
and type 2 (analytical) systems of thinking.1 Type 1 thinking is
effortless and automatic. Using this system, diagnoses can be
made efficiently, and the clinician can transition his or her
cognitive efforts to other considerations. Type 2 thinking is
needed when type 1 thinking does not immediately provide a
diagnosis. Type 2 thinking consists of careful reasoning into a
patient’s presentation and the diagnostic possibilities; it is
deliberate, slow, and requires considerable effort.
Internists are usually quite comfortable with complicated
medical problems when the pathological process includes their
Bbread and butter^ organ systems such as the heart, lungs, or
kidneys. They often have well-developed Billness scripts^ for
many conditions that can be quickly retrieved when
encountering patients with suggestive signs and symptoms. Many
diagnoses are readily retrieved using type 1 (intuitive) thinking when
the problem lies in these organ systems. Internists may be less
comfortable with pathology related to other organ systems such
as skin (dermatology), brain and nervous system (neurology),
and eyes (ophthalmology). In such instances, illness scripts may
be less developed and fewer in number, requiring a shift to type
2 (analytical) thinking.
Our discussant develops a problem representation—unilateral
progressive subacute eye pain and vision loss—and reflexively
searches his immediate memory for corresponding illness scripts
(type 1 thinking). Acute glaucoma is the available illness script;
however, the patient’s young age precludes the common causes of
glaucoma. Hence he converts to type 2 (analytical) thinking.
Specifically, he uses his knowledg (...truncated)