Friday, February 8, 2013

The patient told you what?!?

A fact of medical student (and resident) life is that the Attending will come back from seeing your patient and they will have obtained some very different information.  Hopefully your attending won't gloat too much.  This incredibly frustrating phenomena has some identifiable causes that you have no control over, however there are things you can do to make it happen less often.

One thing not in your control is the power of suggestion.  You ask the patient a really insightful question and they give you an answer.  Then they hang around with nothing else to do but think about better answers to your question.  By the time the attending comes to see them they have developed a better answer:  "Now that I think about it, this pain is just like my last heart attack."

Now that you feel better about this happening, here are some particularly effective questions to extract info from even the most circuitous patient:
  • "What happened that made you come to the ED today?"  For the patient with symptoms not acute in onset.  Be careful that they do not take this as an accusation of poor ED utilization.  I often have to follow up with, "I have found that question most often leads to your  diagnosis."  Which is true.  
  • A variation is, "What brings you in to the ER today?"  Harder to be misinterpreted but you will sometimes get, "an ambulance" or  "my daughter", as an answer - but that is okay, those people probably have really important history you need.
  • "Have you ever had anything like this before?"  The nice thing about history, from a diagnostic standpoint, is that we are destined to repeat it.  The odds are good that the right upper quadrant pain that feels just like their previous biliary colic, is again coming from their gallbladder.
  • "Do you have any medical problems?", when answered in the negative, should be followed with, "Do you take any medications every day?" and "Have you ever had any surgery?".  Many people feel that it is no longer a problem if they are doing something about it, like taking their medications.  If only that were true.  
I hope you find these questions as helpful as I do.

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