Adult Urgent Care Center: Learning to widen my differential

I had the opportunity this afternoon to accompany one of my attendings during her shift at the Denver Health Adult Urgent Care Center. This is like one step down from the Emergency Room, taking patients who are acutely ill but not necessarily a medical emergency.

One patient I saw was an elderly woman who came in with a subjective fever, chills, sore throat, cough productive of green sputum, and shortness of breath. She had these symptoms for 1 week, but she came in today because her shortness of breath got worse and because her throat hurt so bad she could hardly even drink water let alone eat. She has a 50 pack-year smoking history, and she denied any recent sick contacts or travel.

I could hear her wheezing from across the room. On exam I found an inflamed throat coated with a thick white mucus. Listening to her lungs I heard expiratory wheezes but no signs that there might be a fluid buildup.

When we sent her for a chest x-ray, I was thinking mostly about a possible atypical pneumonia or upper respiratory infection. Her presentation was screaming of an infectious cause so much that I didn't really think much of other possible causes of her symptoms.

On further questioning by my attending physician, my patient reported pain in her back, swelling in her ankles, and sleeping propped up on 3 pillows at night. These together raise red flags for congestive heart failure. Her heart sounded great, though, and I only found a trace amount of fluid accumulation in her lower legs. We ran an EKG on her just in case, and it was unchanged from an EKG done a few months earlier when she didn't have these symptoms. This all pointed away from CHF as the culprit.

My attending also drew my attention to chronic obstructive pulmonary disease (COPD) as a possible cause of her symptoms. However, she had recently done pulmonary function tests that were normal, lowering COPD on the differential.

Her chest x-ray came back with no consolidations making pneumonia much less likely. It turns out that she had reactive airway disease from an acute asthma exacerbation likely caused by a viral upper respiratory infection. We treated her asthma with an oral steroid and an albuterol nebulizer, and we treated her cough with cheratussin.

Even though I was partly right about her illness being infectious in nature, and that it was likely viral, I didn’t pick up that her viral infection was causing an acute asthma exacerbation. The expiratory wheezes should have given it away. More frustrating, I zeroed in too quickly on the infectious nature of her illness to the exclusion of other possibilities such as COPD or CHF exacerbation, which were perfectly reasonable to include in the differential given her past medical history.

This is a typical mistake for a third-year medical student to make – and I learned a lot from it.