The Landline as a Useful Diagnostic Aid
The elderly Puerto Rican gentleman—for he was a gentleman—was dressed to the “9’s.” He was
bedecked in a fedora and dressed in a suit and tie. He was accompanied by his
wife and daughter. The daughter was there as a translator. She had been a medic
in the army, was an EMT presently, and was going to nursing school at our
hospital.
Mr. T didn’t speak much English. Mrs. T seemed to understand
but was embarrassed to speak.
Their daughter, Angelica, was a bright and energetic 40 something year
old who loved to talk.
“Dad’s been coughing for well over six months. Sometimes he
coughs until he vomits. He’s short of breath too. He hates coming to the
doctor’s so we had to drag him here under threat of death,” explained Angelica.
Before she could even say anything else, my brain switched
on to the pathways for chronic cough. Chronic cough is a different animal from
acute or even subacute (6 weeks to 3 months) cough. I could already rule out
things like run of the mill bacterial pneumonia. I started thinking about the common things,
like reflux, or post nasal drip. It’s funny how after you’ve been in the
business as long as I have, you can skip ahead in your brain formulating possible diagnoses while the patient is still speaking.
I ran through my Review of Systems, considering other things like autoimmune disease,
drug effects, occupational exposures, and chronic infections like TB and fungal
infections, and of course--cancer.
All of the answers to my queries were, “No.”
No fever or chills.
Appetite okay but the coughing fits
kept him from catching his breath so it was hard to eat.
No, he hadn’t lost any weight.
No, no
swollen glands.
The cough was dry and spasmodic. No, he had never smoked
cigarettes or anything else for that matter.
Angelica had listened to his lungs. “I hear a lot of
crackles. Loud crackles. But I don’t think he’s in heart failure. He doesn’t
have any swelling. I don’t hear a gallop rhythm and his heart seems okay.”
Crackles are a sound in the lungs that can be caused by any
number of things—fluid from heart failure, scar tissue, pneumonia.
Fine crackles sound like rubbing hair between two
fingers next to your ears.
Coarse crackles sound like pulling two
pieces of Velcro apart.
Fine crackles are often fluid in the tissues of the
lungs, and Velcro crackles are often scar tissue in the lungs. People who
sand blasted forms in steel mills, or were bakers, worked in cotton mills,
worked with asbestos or other occupations where fine dusts were inhaled, get
Velcro crackles from damage to the lungs.
Mr. T had never done any of those dangerous jobs.
Sure enough, when I examined him, he had Velcro crackles.
He admitted to shortness of breath with less and less
exertion over time. He couldn’t do the things he enjoyed, like long walks, or
working out, because he was short of breath all of the time.
He wasn’t on any medication that could cause scar tissue,
like amiodarone. I did blood work and a physical exam
looking for autoimmune diseases like
rheumatoid arthritis. Everything was negative.
The chest xray and subsequent CT scan of the lungs revealed
a thickening of the tissues in the lungs—interstitial lung disease.
Pulmonary function tests (breathing tests to see if people have wheezing, or problems with the lung tissues being too thick) revealed that his lungs were stiff,
and oxygen wasn’t getting across the thickened tissues.
I sent him to my husband who conveniently happens to be a pulmonologist.
He couldn’t figure out the cause either. That's saying something because he is one of the smartest people I know.
Meanwhile, Mr. T was getting worse.
His daughter called me one day to discuss his case. We were
going over the test results, talking about where he was born, whether he had
ever gone spelunking (fungus from caves can cause lung disease), whether he’d
worked on a farm (silo’s have fungus in them) and whether anyone else in the
family was sick, etc.
Suddenly I heard a squawking in the background.
“Angelica, is that a parrot I hear?” I asked, suddenly excited.
“Yes.”
“Does your father have a parrot?”
“Yes, he’s had one for years! He loves his parrot!”
“I know what’s wrong. Get the parrot out of the house
immediately and get your father to the office. I need to do a blood test to send to
Northwestern for special testing.”
I called the specialist at Northwestern to get instructions
on how to send the test. We sent it once, and it got lost.
We drew it again and had the daughter deliver it in person.
A couple of weeks later, we still hadn’t heard and called
the lab again. The results were positive. Mr. T had hypersensitivity
pneumonitis to parrots. We had sent an avian antigen panel testing for antibodies
to different birds, but in particular to parrots.
We were fairly certain of the diagnosis before we got the
results back and started Mr. T on high dose steroids, with miraculous
improvement.
My husband STILL uses the case to illustrate the importance
of taking a pet history and for listening for ALL of the clues, even over the
phone.
And THAT is how I diagnosed Avian antigen hypersensitivity
pneumonitis over the phone.
Michele Carlon, MD
DoctorDiva
Just discovered your blog. Love it. Amazing how actually listening to the patient/family and going through that d/dx really yields results. I love your story. So true. I've learned through trial and error (ok, mostly error) that if one sits and listen, and asks questions and listens to answers, and asks more questions and if one gets that robust history ahead of the exam -- the patient diagnoses themselves most of the time. Such a great blog. I'll be bookmarking it. Thank you for writing these posts!
ReplyDeleteThank you! It's true that if you really listen, the patient will tell you the answer! Thanks for reading.
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