The Case Of The Dilated Pupil

What causes the most problems for patients? Ask Dr.Jerome Groopman, Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston. He’s author of the book “How Doctors Think”, which describes a study of 100 incorrect diagnoses.

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Dr. Groopman was interviewed by Dialogue, a publication of The College of Physicians and Surgeons of Ontario. He reports that wrong diagnoses are not usually due to the doctor’s ignorance, but to his or her failure to ask the right questions. For instance, Dr. Groopman relates the story of an 80-year-old man who had been seen by four specialists. The man had only one complaint. He said he suffered from “poor stamina”. During several months specialists carried out cardiovascular, pulmonary function tests along with an extensive endocrine work-up. But following this exhaustive study the only finding was a mild decrease in the male hormone, testosterone. This was not shocking as males normally show a decrease in testosterone as they age. But he was, nevertheless, sent to another endocrinologist. Fortunately, this doctor was imbued with a large dose of old-fashioned horse sense. He asked the obvious question, “What do you mean by ‘stamina’?” The man simply pointed his finger at his legs and said, “I get pain when I walk on the golf course and have no stamina in my legs.”

This straight, to-the-point question made the diagnosis as simple as 2 plus 2 equals four

This straight, to-the-point question made the diagnosis as simple as 2 plus 2 equals four. The patient was obviously suffering from intermittent claudication of the legs. Due to a narrowed artery, insufficient oxygenated blood was reaching his leg muscles, causing pain after walking a few steps. The right question would have saved time and a huge amount of money. The Harvard Medical Alumni Bulletin cites another situation where questioning was vital. A young boy had been playing in his room when he suddenly developed a headache and blurred vision. His parents rushed him to Emergency where examination showed a dilated pupil of his left eye. This is not a good sign as it can indicate a tumour or an aneurysm of the brain, a terrifying situation for parents. The parents advised the doctor that their child had always been in good health, had no previous eye injury and did not use eye drops. Eye examination failed to reveal increased pressure or other problems. The doctor then recalled a patient, a researcher, he had seen years ago, who also had one dilated pupil. This researcher had accidentally spilled atropine on his finger, then rubbed his eye. Atropine is extracted from flowering plants and during the Renaissance women would dab a bit of the juice on their eyes to dilate the pupils, thinking it made them more attractive. But the parents again stressed their child was not using eye drops. However, it’s an old medical maxim that if you talk long enough, the patient often tells you the diagnosis. So the doctor persisted and said, “Are you sure no one in the family is using eye drops?” Suddenly the boy’s mother said, “Oh, my God, what are we putting in Fluffy’s eyes?” They had forgotten a veterinarian had prescribed eye drops for the cat. It turned out they contained 1 percent atropine. Some of it had been transmitted to the fur and thence to the boy’s eye. It remained dilated for another seven days. In another case a kindergarten girl developed a headache and began bumping into things. Parents told doctors she was not taking any medicine. Standard tests showed nothing worrisome. But an MRI revealed a strange whiteness of the optic nerves. Then an ophthalmologist discovered she was almost blind. Later, a lumbar puncture revealed pressure in her skull was twice the normal level. This is an ominous finding, but nothing could be found to explain her problem. The family became annoyed at being asked repeatedly if the girl was taking medication. Finally the doctor asked, “What about vitamins?” Her Mother replied, “Does fish oil contain vitamins?” It turned out she had been given the recommended daily adult dose of Smith’s Fish Emulsion. This adult dose had caused vitamin A toxicity. The moral? Asking the right question, perhaps repeatedly, can save a ton of money and worry.

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