History Lesson

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I love it when the lecturers say the same thing. “Take a good history…” They act as if we don’t know what questions to ask. Don’t they get it? The right questions are all written out on the template. Sometimes I just don’t know what to do with what the patient tells me. Ever had one like this?

“Hi, I’m Doctor Plaster. What brings you to the emergency department tonight?”
Patient on the bed gives a dumb look. “She dahsn’t speak English,” says the woman sitting disinterestedly at her side eating some peanut butter crackers and drinking a soda. “She’s from Cahm-ah-rooon.”
“That’s cool,” I said. “Are you a relative?”
“No,” she said, ignoring me and scanning the room with her eyes.
So much for the ‘open ended question technique’, I thought. “Where does your stomach hurt?” I asked. Somehow the triage nurse had gotten out of this woman that her problem was ‘abdominal pain.’ The friend talks to the patient for two minutes.
“All over.”
“Up here, down there, where?” I point to the different quadrants. They talk for several minutes with the patient rubbing all over her abdomen and groaning. “Where does it hurt?”
“Up there,” says the friend, pointing in her friend’s general direction.
“Up here?” I ask pointing to her stomach region.
“Here?” pointing to the gall bladder region.
“Here?” poking the belly button.
“Well, where then?” They talk for two minutes.
“Here,” she says pointing to the left lower quadrant. And sitting back down.
“I thought you said ‘up there’.
“That’s right.”
OK, I thought. At least I know it’s left lower quadrant pain. “How long has it been going on?” They talk more.
“A while.”
“A long while or a short while.
“A short while.”
“Just how long is ‘a short while?’” I ask, thinking I’m clever.
“Since her mother died,” says the interpreter with a sorrowful look.
“I’m sorry to hear that. How long ago did her mother die?”
“A while.” But this ‘a while’ seemed to have a different upward inflection. Maybe it was longer than I thought. Oh well.
“What does the pain feel like?” I asked working further down the template. They talked for several minutes.
“She says it feels like her stomach is talking to her.” I took my glasses off and rubbed my face.
“What does her stomach say?” I ask in my ‘talk to the baby voice.’ Is it the voice of your mother telling you to clean your room or is it the dog telling you to kill the neighbors! Now I was the one hearing voices.
Both women looked at me blankly as I returned from my internal conversation. “Is there anything that seems to make it better or worse?” I ask in my telemarketer voice.
“The television,” she says after interrogating the patient.
Does watching TV make it better or does eating the TV make it worse! Uh, oh. I’m losing it now. My face is getting red and my eye is starting to twitch. Oh, wait a second! My eye catches a box next to a phrase at the beginning of the chart.
‘Unable to obtain history due to ____________.’ Well that does it. The history is unobtainable because: a) the patient is a moron, b) the interpreter is a moron, and c) the doctor is a moron. I’m shaking my head. I’m having an out-of-body experience. Despite all this I attempt a Review of Systems. You can guess the result.
The physical exam wasn’t much better. Everything appeared normal until I tried to palpate her left lower quadrant. Then she grabbed my hand and moaned. Her friend looked at me like I was attempting to violate her.
A professor of mine in medical school used to tell us “The diagnosis is made by the history and confirmed by the physical exam. Only the weak clinician needs the lab to make a diagnosis.” Well, I admit it. I’m a weak clinician. I ordered a CT scan based on …well she needed it. I also ordered every blood and urine test I could think of. At least it gave me some time to get away from her and think.
When all the test results came back she had a normal urine, negative pregnancy test, slightly high white count, and a non-diagnostic CT. I called the surgery resident.
“I’ve got a hot abdomen down here that you need to see and admit,” I said with some authority over the phone.
“How bad is it?”
“Oh, real bad,” I warned.
“Does she need surgery tonight?”
“Well, I wouldn’t want to tell you how to do your business,” I demurred. “I’ll let you determine that.”
“Were you able to punt that case to surgery?” my partner asked with begrudged admiration as he watched me kick an air football.
“Look at the hang time on that baby,” I said doing a little end zone dance. But before I could even pick up another chart the surgery intern appeared.
“Five bucks says that case will be back in your lap before the end of the shift,” he goaded.
I picked up several more charts hoping to hide in the patients’ rooms so the intern couldn’t find me. I chuckled to myself when I glanced in the room once and saw him listening intently to the interpreter. He’s Korean and she’s Cameroonian. He won’t get past her name.
After an hour I thought the coast was clear and I could come back out to the nurses station. But just when I thought the patient had been taken upstairs, I saw the intern come out of the room and walk over toward me.
“Wow, you are quite a clinician, Dr Plaster,” he said admiringly. “I would have never gotten that diagnosis from her history and physical. How did you discover that she had intermittent sigmoid volvulus?”
“Uh, …wha…uh…well,” I paused and took a deep breath through my nostrils.
“I didn’t even think of it until she showed me her medical records from the Mayo Clinic.”
“She had…” I stopped myself.
“We’ll admit her to our service for observation, just in case she needs surgery. Great case!”
“Great case,” my partner mocked.
“How was I supposed to know she had a previous workup? Besides that it was on my differential, too. Just a little further down the list,” I mumbled as he walked away. “I knew she was sick,” I called out to him.
My wife was in high gear when I walked in the door the morning after the shift. “I need for you to take out the trash,” she said, “it’s piling up in the mud room and starting to smell. And take the van up to the service station for an oil change.”
“Hey, what happened to ‘Hi honey, how was your night?’” I was doing my best June Cleaver imitation.
“Get your sleep, but when you get up I have some things for you to do. You need to start pulling your weight around here, buddy.” It was obvious that she had been stewing on this all night. “How long has it been since you took out the trash, huh?”
“A while,” I said. “A short while.”
Mark Plaster, MD, the founder/editor-in-chief of Emergency Physicians Monthly, practices emergency medicine in Baltimore. MPlaster@epmonthly.com


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