Dr Huang’s Clinical Reflections (9)
Patients Can Bring a Diagnosis, but Doctors Should Not Bring One Into the Consultation
By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)
Patients often arrive with a diagnosis already in mind.
They may bring an X-ray, MRI report, previous medical opinion, information from Google or YouTube, or even an AI-generated explanation.
All of this can be useful.
But none of it should replace an independent clinical assessment.
Imaging can tell us what structures look like. Previous diagnoses can tell us how someone else interpreted the case. But the treatment decision we make today should still be based on the patient’s current symptoms, physical examination and clinical reasoning.
Patients can bring a diagnosis into the consultation.
Doctors should not.
A Young Patient Who Thought He Needed Cervical Manipulation
A few days ago, a young patient called for an urgent appointment.
He had recently undergone a cervical X-ray and believed he had a cervical spine problem. He wanted to come in for spinal manipulation.
I told him, “You can come in, but whether the problem is actually coming from your neck, and what treatment you need, will depend on what I find when I assess you.”
For the previous one to two months, he had been waking almost every night because of pain.
The most painful area was not his neck. It was around the lower part of the upper arm, just above the elbow, mainly on the posteromedial side. He also experienced numbness and pain along the little-finger side of both hands.
The symptoms were worst at night.
When the pain woke him, moving the arm sometimes made it feel slightly better.
During the day, he was often relatively comfortable, although looking down at his phone or getting in and out of a car could occasionally trigger numbness in the little fingers.
In his mind, the diagnosis was already established:
cervical spondylosis.
He had come to see me expecting treatment for his neck.
Starting With the Neck, but Not Stopping There
Numbness affecting the little finger and ulnar side of the hand can certainly be related to the cervical nerve roots.
Pain around the upper arm and elbow can also occur with cervical nerve irritation.
So I started there.
I performed cervical provocation testing, including compression-based examination, but these tests did not reproduce his familiar numbness or upper-arm pain.
I then examined other proximal areas that can affect the brachial plexus or thoracic outlet, including the scalene muscles, subclavius and pectoralis minor.
There was some tenderness, but again, pressure in these areas did not reproduce the numbness in the little finger that he knew so well.
At this point, I started to question the original assumption.
If the main problem was coming from the cervical nerve root or proximal brachial plexus, why were the relevant tests failing to reproduce his typical symptoms?
The Examination Changed the Direction
The patient’s most painful area was close to the elbow, and his sensory symptoms followed a clear ulnar distribution.
So I examined the ulnar nerve around the elbow.
When I pressed around the cubital tunnel and along the ulnar nerve above and below the elbow, his familiar little-finger numbness was reproduced almost immediately.
There was also marked local tenderness.
This was very different from what I had found at the neck and thoracic outlet.
For the first time during the examination, I had reproduced the symptoms accurately.
That changed the direction of my thinking.
I became increasingly suspicious that the main problem was not the cervical spine, but irritation or entrapment of the ulnar nerve around the cubital tunnel.
Treatment Should Follow the Examination, Not the Label
After the examination, I explained my reasoning to the patient.
I said:
“If I simply followed the diagnosis you brought with you, I would manipulate your neck today. But based on what I have just found, I do not think your main problem is coming from the cervical spine. So I am not going to treat the neck just because that was the original diagnosis.”
I also told him that if he remained convinced that cervical manipulation was what he needed, he was free to seek another practitioner.
But if he was willing to follow my reassessment, I would treat the ulnar nerve region around the elbow instead.
Eventually, he agreed.
That day, I treated the cubital tunnel and surrounding soft tissues using acupuncture, local release techniques and cupping.
I did not promise that he would improve.
I only asked him to report honestly the next day whether he was better, unchanged or worse.
What Did the X-Ray Really Tell Us?
Later, the patient sent me a photograph of his cervical X-ray.
He was in his twenties.
The overall alignment and disc spaces appeared reasonably preserved. There was no obvious severe degeneration or major bony abnormality that clearly explained bilateral little-finger numbness and nocturnal upper-arm pain.
The cervical curve appeared somewhat straightened, but that finding alone does not prove cervical nerve-root involvement.
More importantly, a standard X-ray mainly shows bone.
It does not directly show the intervertebral discs, nerve roots or the exact site of peripheral nerve irritation.
So whether the X-ray appeared normal or showed minor changes, it still could not answer the most important clinical question:
Where was the patient’s numbness and pain actually coming from?
That answer still depended on the history and physical examination.
The Next Morning
The following morning, the patient sent me a message:
“The pain is about half better, and the numbness is about one-third better.”
For me, this did not prove that the diagnosis was correct.
One treatment response cannot establish a final diagnosis. Symptoms may also fluctuate naturally, and rest or other factors may contribute.
But the improvement did provide some additional support for the direction of the assessment and treatment.
If I had simply accepted the diagnosis of “cervical spondylosis” and manipulated the neck without reassessing the patient, the entire treatment could have continued in the wrong area.
Imaging Is Important, but It Should Not Think for Us
Patients today have access to more medical information than ever before.
They may arrive with a GP diagnosis, imaging report, online research or AI analysis.
These can all be valuable.
The danger begins when the answer appears before the examination.
If the patient says “cervical spondylosis,” the clinician may start looking only at the neck.
If an MRI shows a disc bulge, every symptom may then be explained through that finding.
But an imaging abnormality is not always the source of symptoms.
And the absence of a major imaging abnormality does not mean that a nerve problem is not present.
I will always review imaging carefully.
But I do not want the image to think for me.
My Clinical Reflection
Over the years, I have become less willing to accept a diagnosis simply because it has already been written down.
Not because the previous clinician was necessarily wrong.
Not because imaging is unimportant.
But because every assessment happens at a particular time, and the patient’s symptoms may change.
Reassessment is not about rejecting previous conclusions.
It is about taking responsibility for the patient sitting in front of us today.
We need to retake the history, examine the symptom distribution, reconsider nerve roots and peripheral nerves, and decide whether further investigation or referral is needed.
If the final conclusion is the same as before, that is fine.
At least it has been independently verified.
One of the most dangerous things in medicine is not having no answer.
It is believing too early that we already have one.
This case may still require follow-up. Bilateral symptoms mean that cervical nerve roots, proximal nerve pathways and other possible causes should continue to be considered.
But the lesson remains simple:
Diagnosis should not come before examination, and treatment should not come before diagnosis.
Patients can bring a diagnosis into the consultation.
Doctors should not bring one with them.
Book a Clinical Assessment
If you have been given a diagnosis but your symptoms still do not fully make sense, an independent clinical assessment may help clarify whether the current diagnosis matches your actual symptoms and examination findings.
Book online:
https://booking.mananotes.co.nz/PHD-WIN/v2
Disclaimer
Disclaimer:
This article is for general educational purposes only and does not replace individual medical assessment, diagnosis or treatment. Numbness, weakness or persistent neurological symptoms may have multiple causes and may require further medical investigation or referral.
Related Reading
Dr Win’s Clinical Thinking (11) A Doctor Sees More Than a Diagnosis — They See Clues
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