Clinical Problem-Solving: Diagnosis by Drug Reaction

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Abstract
The Clinical Problem-Solving case “Weak Reasoning: Diagnosis by Drug Reaction” (Feb. 4 issue)1 underscores how essential a focused history is in the initial evaluation of an acutely ill patient. Given the amount of effort that went into arriving at the ultimate diagnosis of myasthenia gravis, it is ironic that this young woman with chest congestion, shortness of breath, and acute respiratory distress was not asked the simple question, What is your occupation? It would also have been useful to know whether she had come from work, home, or elsewhere. Although there was a brief mention near the end of the case that she had denied exposure to pesticides, her initial presentation could easily have been consistent with metal fume fever, polymer fume fever, or hypersensitivity pneumonitis2. Occupational asthma would be less likely but possible. Such exposures can occur in both large and small industries, affecting both men and women. The value of taking a simple occupational history lies in the fact that all these disorders can be readily reversed by removing the patient from the place of exposure.

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