Mystery of patient's incomplete history
Posted on 13 February 2013 by Tim Cantor
A middle-aged woman comes to see me in surgery. She tells me that she has had the sensation of a foreign body in her left eye for the past two and a half weeks.
She thinks that it is an eyelash. She has had this problem before, and it feels just the same. Her concern and mine are somewhat increased by the fact that she is having treatment for glaucoma.
I examine the eye. It looks entirely normal. There is no inflammation, the cornea looks fine, and I cannot see an eyelash or any other foreign body within the conjunctival sac.
In spite of having attended the Moorfields GP refresher course two years ago, ophthalmology is not my strongest specialty. When confronted with a patient with eye symptoms for which I can provide no explanation, my natural instinct is to assume that I must be missing something. I ask her when her next glaucoma check is due in the hope that it might be imminent.
It is not; it is two months away. The obvious next step is to refer her to the local emergency eye clinic, where she is likely to be seen within 24 hours. However, my local PCT is very strapped for cash, and I am reluctant to waste what money it does have by initiating what may well be an unnecessary referral.
Experience has taught me that when in doubt it is usually best to be honest with patients, so I tell her that I am mystified by her problem. On the one hand, she gives what sounds like a very good history of a foreign body in her eye.
On the other, I can find no signs of the conjunctival inflammation I would expect after a foreign body had been present for two and a half weeks. She hesitates and then replies with some honesty of her own. She confesses that the sensation of a foreign body in her eye ceased three days ago.
We agree that she probably did have a foreign body in her left eye, but it has dropped out of its own accord and no treatment is required. She seems satisfied by this explanation.
As she leaves the room, I cannot help thinking that the consultation would have been a lot easier if she had volunteered that crucial piece of information at the beginning rather than the end. If she had done so, the consultation would have lasted five minutes rather than 15.
It is easy to forget that some patients, in spite of being of apparently sound mind, choose to give doctors incomplete and misleading histories, even when there is nothing obvious to be gained by doing so. In this particular case, I suspect that she made the appointment while she still had symptoms and wanted an opinion in case they returned.
Tim Cantor is a sessional GP in Kent
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