Thursday, November 15, 2007

Listen, the patient is telling you the diagnosis

There's an old saying attributed to Sir William Osler that you'll hear dozens of times even one year into medicine:

Listen, the patient is telling you the diagnosis.

We've also been told that if you've done an extensive list of investigations and still don't know what the patient has, re-taking the history can sometimes bring a diagnosis to light.

Being able to spend time in clinic is great, but to be honest, we don't really know what questions to ask yet. Yeah, we know a few: does it hurt? how much? where? and for how long? But it takes a long time and a lot more training to learn all the important associated conditions - that I should ask the patient with Crohn's disease if their joints hurt, or the patient with chronic hypertension how their vision is.

Some of these things come second nature for doctors who have been doing this for years, but when you're new at this, you feel like getting a diagnosis just by asking the patient a few questions can be pretty difficult.

Getting the diagnosis from the history has started happening to me, though. At my clinical exam at the end of the year (the OSCE - Objective Structured Clinical Exam) where medical students go from room to room at the sound of the tone, read the instructions on the door, then either take a history or do a physical while an examiner watches, there was one station I won't forget - I figured out what the patient had, just by asking the right questions.

She presented with a cough. As I asked her more and more questions, I was able to determine that she had been coughing up blood, and she had been exhibiting what are known as constitutional symptoms - fever, weight loss, and fatigue - all indicating a serious, chronic condition. As I finished asking her my questions, it began to dawn on me in my head... oh my gosh, lady, you've got lung cancer... and you've probably only got a few years left to live.

Okay, yeah, the patient was an actor, and it was a strucutred environment, and that was the point of the entire exercise, but it was still a neat feeling to almost be certain about a patient's diagnosis just by asking her some questions.

I was pretty excited about my success. Inevitably, however I came crashing down to earth while chatting about that patient with another student.

I'm still kicking myself - as I spoke with my friend I realized I didn't ask the patient the most obvious respiratory history question:

"Do you smoke?"

I won't make that mistake again.

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Monday, November 05, 2007

Can't be too careful with physical exams...can I?

"Well, given the problems you've mentioned, I'm going to need to do a quick physical exam."

Now that I'm in second year, that's something that I've been able to do, and be confident doing: if a patient presents to me in clinic with an ear/nose/throat issue, a heart or lung problem, a musculoskeletal problem, or an abdominal problem, I'm able to do a focused physical exam before the doctor comes in.

"The doctor will come in and do an exam as well in a few minutes, but for now could you lay on your back and lift up your shirt so I can examine your abdomen please?"

I turned my back to wash my hands as the patient, a friendly, effervescent girl my age, set her backpack down from her lap and hopped up onto the exam table.

She had been explaining that she had been going #2 once every four or five days, and that was "normal" for her, and even though she had been that way for a while she constantly felt abdominal pain and fullness and bloating. So, after asking her a few more questions, I decided to put my new-found gastrointestinal clinical skills to good use and see if I could palpate any abdominal masses or liver enlargement.

I dried my hands, threw the paper towel away, and turned back to the patient. "I'll just start with a general visual inspection before I begin the exam, looking for asymmetry or scars or any abnormalities," I explained,

before I moved on to the hands-on part. Everything looked normal.

"Now, I'm going to do a procedure called percussing your liver, which basically involves me sortof tapping on your stomach. Your liver is a bit behind your rib cage so can I ask you to lift your shirt just a bit more?"

Her shirt was only half exposing her stomach, and in order to percuss the whole liver the shirt usually needs to be lifted up to right where the bottom of the bra is. (On a really good exam the patient would be in a gown and that wouldn't be an issue, but in clinic I'm not going to ask a patient to gown up for an abdominal exam.)

I always feel awkward asking a patient...especially a girl...especially one my age... to remove more clothing, so I try to explain myself really well. As well, despite what I've seen some doctors do, I always try to get the patient to remove their own clothing rather than 'help them out.'

She complied without hesitation, and pulled up her shirt a bit... but when she let go, it fell back down to basically where it was before.

Great, I thought. Now I have to ask her to lift her shirt again. Awkward.

I worked up the courage and asked again. "Um... could you lift it a little bit higher please? Just about an inch or two, just to expose the whole liver."

"Sure!" she replied. She grabbed the bottom edge of her shirt and promptly pulled it ALL THE WAY UP to her neck, revealing her entire chest, pink bra and all.

Call me a prude, or whatever you want, but I had a bit of a minor freak-out.

"Woah.... no, no! It's okay! Not that high!" I exclaimed reflexively. I almost grabbed her shirt and pulled it down.

"Um... Vitum..." she said slowly, almost condescendingly.

"Yeah?" I murmured.

"It's okay...

...You're a doctor."

Up until then I had never before been corrected for being too cautious, and it was a bit of a relief to have a patient remind me that while it is important to be respectful of a patient's privacy, it's also important to be thorough. That's what patients are expecting when they see the doctor, after all.

It's still gonna take some getting used to, though, being able to tell complete strangers to remove their clothing, and while this might not seem like that big a deal I still try to be very careful around issues like this. Hopefully I don't ever get too comfortable, though. And for now, I think I'll try to always err on the side of modesty.

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