DartosMD

Doctor here. It's not a question of incompetence. It's a question of convenience for the patient. Everyone would like a 100% accurate diagnosis 100% of the time for every visit however, this is just not possible or practical given the time and economic constraints of outpatient medical practice. Nor is 100% accuracy necessary for relatively minor and common symptoms. The vast majority of health complaints for a previously healthy 20 something either resolve on their own or have a common and easily treatable condition such as asthma or reflux. I.e. only a tiny percentage of young patients seen for a cough are likely to have a mediastinal lymphoma and so Xrays are not commonly ordered at the first or even second or third visit. The decision to order more advanced testing (like a chest Xray) depends on the severity and acuity (duration) of the symptoms combined with other factors like past medical history and associated symptoms that may increase the statistical likelihood of a condition more serious than just a cough. This type of step-up in diagnostics for symptoms that persist after initial conservative treatment is essentially standard of care.

Now, that being said, a doc who spends more time with their patient getting a proper detailed history and exam MAY be able to increase the accuracy of their differential diagnosis and determination of which patients need further work up. In our current system, docs are paid per visit and so their schedules are packed and "shortcuts" are taken (treatment given for the most likely causes without making a definitive diagnosis) for minor complaints that need to be compressed into a 10-15 min visit. Statistically this works out since - again - most of the patients will get better no matter what is done and those with continued symptoms will get more work up or treatment. This pattern may repeat over 2 visits or 4 or more. That's not important as long as the correct diagnosis is made within a resonable period of time so that the prognosis is not altered (so that it's not too late). The down side is that the patient is frustrated at the continued symptoms and the need to return for numerous visits. However, this would not necessarily get better in a socialized system such as the UK's NHS where there is even more pressure to constrain costs through central planning and limited resources.

Yes, a large pleural effusion should be detectable especially if it was mostly or only on one side. This should cause a significant and detectable difference in the breath sounds on auscultation of the chest. However, it's impossible to know if your shortness of breath was caused by a significant pleural effusion back in February or whether there were other reasons for your symptoms such as anemia (low white count) or partial compression and blockage of a bronchus (one of the airway branches of the lung), etc. etc. Often there are several causes for a specific symptom for a given condition which makes these kinds of speculations very complex.

Edit: Suspecting a pleural effusion on exam should prompt more concern and further studies since this is not at all commonly associated with common causes of cough nor seen in otherwise normal 20 year olds.

Edit/correction: Anemia = low blood count (Hb). Leukopenia = low white count. My bad.

There are two possibilities. 1. The doc missed the findings of a pleural effusion that would have led to an earlier diagnosis or 2. The effusion was not large enough to be detected on exam until several months later.

Either way, congrats on the cure!

Paradoxically chronic daily marijuana use has been associated with CVS. However, it's more complicated than that. Chronic marijuana use associated with daily vomiting and frequent and obsessive bathing/showering after vomiting has been termed "cannabis hyperemesis syndrome" and this resolves with abstaining from cannabis use. Correct diagnosis requires stopping the marijuana use for two weeks to see if the vomiting resolves. If not OR if there is no history of marijuana use then CVS is a more likely disagnosis and may improve with cannabis self-medication (or moving to Colorado).