Sunday, December 14, 2008

ALL the questions

"If you finish the history without a clue to the diagnosis, you have a problem." I remember those words well. Spoken by our instructor in Physical Diagnosis during the second year of medical school their corollary was, "And if, after your physical exam, you still have no idea what is wrong with the patient then you are in real trouble."

I doubt that such warnings are issued today when young, eager medical students are taught to take a history from the patient. Today the patient more often than not, will tell you what is wrong by sighting Internet sources where she read about her symptoms.

As a second year medical student I carried a five by eight inch light blue card in the pocket of my white coat. On this card, in very small type, were lists of signs and symptoms I was in the process of memorizing. Not only were these queried to patients in the process of taking their history but the answers were all carefully recorded for completeness in my own hand on the patients chart. In this computer age such things are now recorded by a key stroke.

Approaching my first patients with this list I was careful to ask about breathing, sleeping, bladder and bowel habits, skin problems, leaving the reporting of no symptom to chance in my quest of the diagnosis. Interestingly a second year medical student occasionally made a remarkable diagnosis even though he was the fourth or fifth person in the chain to speak with and examine the patient. The diagnosis often came as the patient answered a question everyone else forgot to ask.

This tradition of speaking with the patient and carefully examining her is what physicians refer to as the history and physical. H and P for short. Time taken to listen to as well as to ask about symptoms. Time taken to touch, peer into, listen, followed by time taken writing down these symptoms and signs. This is how a diagnosis is made and how a treatment plan is formed. Or at least that was the case before CT scanners and instantaneous blood test results. I am ashamed to admit that often I see the results of such tests before I see the patient. I will also admit that reversing this order frequently results in misdiagnosis.

Several weeks ago a patient was referred to me for treatment of pelvic inflammatory disease. A sixty-seven year old widow, she presented to her internist with pelvic pain and fever. The internist ordered a sonogram which revealed an ovarian mass interpreted by the radiologist as a pelvic infection.

One of my questions to the patient as I went over her history was when she had last been sexually active. She admitted that her husband was impotent and she had not had sex in many years. While all of her symptoms and the pelvic sonogram fit with the diagnosis of pelvic inflammatory disease, her history did not. As I began to ask her about bowel habits the fact that she probably had inflammation in her colon became apparent. Last week she had definitive surgery to correct the problem.

Saying all this is patting myself on the back and that is not my point. The point is that it is necessary to ask all the questions. This patient's sexual history was critical to the diagnosis of her illness and proper treatment. The diagnosis was not made by a laboratory test or by a scan of body parts. It was made by questioning and examining the patient. And yes, I had a pretty good idea of what the problem was when I finished asking ALL the questions.
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