"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Small Things Considered: Sometimes in medicine, it’s the little things that’ll make or break you. Recently, one of my patients called and told my receptionist he wasn’t feeling so well and wanted to be seen. That’s a routine request from a patient, but not for this patient. Usually, when he wants to see me he tells the staff he needs to speak with me. When I call him back he asks, "Is it OK if I come by and see you?" Almost like one friend calling another and asking if it’s OK to drop by for a visit. And that’s what his office visits always turn out to be - social visits. When he arrived, the medical assistant took him back to the exam room and I could hear him making his usual jovial banter. Except for one small thing. He sounded a little short of breath as he walked down the hall. By the time I saw him, he was no longer short of breath, but sitting as usual in the chair in the corner and greeting me with his usual “How ya doin’, kiddo?” Except for one small thing. His blood pressure was about thirty points lower than it usually is. He gave me a history that sounded suspiciously like an intestinal virus. Nausea, vomiting, poor appetite, abdominal cramping. Except for one small thing. He went to bed shortly after the symptoms started the night before and woke up that morning feeling short of breath. To tell you the truth, he looked pretty good sitting there in my exam room. Except for those several small details, which made me uneasy enough to get an EKG. And sure enough, there was a full blown myocardial infarction in all of its electrophysiologic glory. Those small, seemingly inconsequential details, made all the difference in the diagnosis. Unfortunately, it didn’t make much difference for my patient. He died a few hours later.
Another patient not long ago. Her mom called for her appointment, as she usually does, even though my patient is in her sixties. She had been in the emergency room the night before for the flu and they noticed her blood pressure was high. She had been instructed to make an appointment to have her blood pressure medication adjusted. She had so many things to tell me at her visit - she needed referrals for her eye doctor, her foot doctor, her mammogram. Her diabetes was better, her struggle with her weight wasn’t. She wanted to see a surgeon to have gastric bypass surgery. She had diarrhea, she had nausea. Her bladder leaked when she coughed. Her joints ached. She had a headache. She had sinus congestion. She had a cough. She had indigestion. Her exam was normal except for mildly elevated blood pressure. So, I made the adjustments in her blood pressure medication and arranged for a follow-up within the next week to see if the changes worked. The next day, her mother called to say she was incoherent. Back to the ER. She had a subarachnoid hemorrhage. Her life’s still in the balance. Distracted by a myriad of small details, I missed the forest for the trees. Damn details. posted by Sydney on
10/09/2003 12:17:00 AM
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