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 written on the template. But sometimes I just didn’t know what to do with what the patient told me. Let me give you an example.
“Hi, I’m Dr. Plaster. What brings you to the emergency department tonight?”
The patient on the bed gave an empty look. “She dahsn’t speak English,” said a woman sitting disinterestedly at bedside eating 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 looking around the room.
So much for the open-ended question technique, I thought. “Where does your stomach hurt?” I asked. Somehow the triage nurse had learned that the patient’s problem was ‘abdominal pain.’ The woman sitting by the bed spoke with her friend for a few minutes, then turned back to me.
“Up here, down there, where?” I pointed to the different quadrants. The ladies talked for several minutes more with the patient rubbing all over her abdomen and groaning.
“Up there,” said the woman pointing in the general region of her friend.
“Up here?” I asked, pointing to her stomach region.
“Here?” pointing to the gall bladder region.
“Here?” poking the belly button.
“Well, where then?”
They spoke for a few more minutes. “Here,” she finally said, pointing to the left lower quadrant.
“I thought you said ‘up there.’”
OK, I thought. At least I know it’s left lower quadrant pain. “How long has it been going on?”
The ladies talked some more. “A while.”
“A long while or a short while?”
“A short while.”
“Just how long is a ‘short while?’” I asked, thinking myself clever.
“Since her mother died,” the woman said with a sorrowful look.
“I’m sorry to here that,” I responded. “How long ago did her mother die?”
“A while.” This time her words seemed to have a different upward inflection. Maybe it was longer than I thought…
“What does the pain feel like?” I asked, working down the template.
They talked for several more minutes. “She says it feels like her stomach is talking to her.”
I took off my glasses and rubbed my face. “What does her stomach say?” I continued. 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 hearing voices. Both women were looking at me blankly when I’d returned from my internal conversation. “Is there anything that seems to make it better or worse?” I asked, reading further down the template.
“The television,” the interpreter said after questioning her friend.
Does watching TV make it better or does EATING THE TV MAKE IT WORSE??? My face was getting red. Oh, wait a second! My eye caught sight of 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, or c) the doctor is a moron.’ I shook my head. I seemed to be having an out-of-body experience. Despite all this I attempted a review of systems.
The physical exam wasn’t much better. Everything appeared normal until I tried to palpate her left lower quadrant. Then the patient grabbed my hand and moaned. Her friend looked at me as though I was attempting to violate her.
A professor of mine in medical school used to say, “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’ll admit it; that night I was a weak clinician. I ordered a CT scan as well as every blood and urine test I could think of. At the very least they would allow me some time to get away and reflect on the situation.
When all the results had come 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.
My partner watched with begrudging admiration as I kicked an air-football. “Were you able to punt that case to surgery?” he asked.
“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.
My partner grinned. “Five bucks says that the case will be back in your lap before the end of the shift,” he goaded.
Picking up several charts, I hoped to avoid the intern by hiding in the patients’ rooms. I chuckled to myself when I glanced over 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 was sure that the coast was clear and returned 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 to me.
“Wow, you are quite a clinician, Dr. Plaster,” he said sincerely. “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!” The intern insisted before exiting the room.
“Great case,” my partner mocked.
“How was I supposed to know she had a previous workup? Besides that 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.
After my shift I returned home to find my wife in high gear. “I need for you to take out the trash; it’s piling up in the mud room and starting to smell. And take the van to the service station for an oil change.”
“Hey, what happened to ‘Hi honey, how was your night?’” I attempted 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 sighed. “A short while.”
EPMonthly is excited to announce the upcoming publication of Mark Plaster’s...
Short Stories from the Life of an ER Doc”
Based on more than 30 years of experience in emergency medicine, the book features a collection of articles originally published in Emergency Physicians Monthly.
– Introduction by the author
– Foreword by Dr. Greg Henry
Available for purchase - October 2013