Empathy as a Diagnostic Tool in a 33-Year-Old Man with Eye Pain and Vision Loss: Exercises in Clinical Reasoning

Journal of General Internal Medicine, Jul 2016

Reaford Blackburn, Carlos A. Estrada, David McCollum

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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 - 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)


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Reaford Blackburn, Carlos A. Estrada, David McCollum. Empathy as a Diagnostic Tool in a 33-Year-Old Man with Eye Pain and Vision Loss: Exercises in Clinical Reasoning, Journal of General Internal Medicine, 2016, pp. 1389-1392, Volume 31, Issue 11, DOI: 10.1007/s11606-016-3797-9