Wednesday, September 18, 2013

Diagnosis Of The Week

Thanks for stopping by, and helpfully signing in with everyone's favorite chief complaint:
tummy ache.

Sometimes, you helpfully narrow it down to a flank or a quadrant, and other times, not so much.

Which is why it's called Mystery Abdominal Pain.

Which occasions the triage nurse getting out their deerstalker cap and meerschaum, and playing Sherlock Holmes with you, crossed with a really thorough police interrogation. (Tip to family members: shaddup, and let us get the answers the patient has. We'll be happy to let you fill things in afterwards, but first things first, 'kay?)

For the anatomically vague, a brief lesson.
Chest pain is rather straightforward, there being far less "stuff" to deal with: heart, two lungs, ribs and muscles. Yes, there are other things there for more detail-oriented folks, but that's the highlights. And even then, >5 out of 10 patients with chest pain go home with a diagnosis of "atypical chest pain", which means it's probably not a heart attack, pulmonary embolism, broken ribs, aortic aneurysm, tumor, or 27 other things, and we don't know what it is, but we're relatively certain it isn't going to kill you - tonight, anyway.

Abdomens are a bit more problematic. You have a diaphragm, esophagus, stomach, liver, gall bladder, two kidneys, pancreas, spleen, two different intestines, an appendix hanging out down in the corner, and for those with the internal plumbing option, a full set of female tackle for gestating and producing offspring.

Things that'll kill you relatively soon are things like appendicitis and an ectopic pregnancy. Everything else may only make you wish you were dead. We'll be focusing on the life-threatening options first, and trying to narrow things down as we move along.

Either way, to find out, we're going to need to do a few things. Things like blood tests for standard labs, a CT and/or ultrasound, and we need your pee to make sure you aren't pregnant. For the record, the more sure you are that you "couldn't possibly be" so, without a picture of your uterus in a jar, for any female between about 5 and 50, generally just convinces us you're lying at worst, and mistaken at best, so work with us, and just give up the pee, 'kay?

This is where you can shine, and help yourself: see that computer you're reading this on? When you finish, go to your word processor, and type in your allergies, medical history (that means the things someone with "M.D." after their name has actually clinically told you you have, not the things you Googled before you came in or think you have), along with any surgeries, and a pretty good breakdown on your problem as you understand it.

Unless you had 42 abdominal surgeries in your teens, we really don't want the entire unexpurgated life history of your alimentary canal since 3rd grade, but if you do have some serious issues, by all means fill us in. Start with why you're here right now.

Then, if applicable, recall your last menstrual period, particularly if it seems to have been 8 or 9 months ago.

And if you have an IM, gastro, gyno, renal, etc. specialist(s) you see or have seen, by all means, their name and phone number.

Minus points if you deny significant history, and then we find a scar around your middle big enough to swap body parts, or even find those cute little nicks on the sides that tell us someone's been worked on by laparoscopy.


Re-read that menu above, and note that it doesn't contain double cheeseburgers, anchovy pizza, or Flaming Hot Jalapeno Cheetos, or anything else, whatsoever. Try and remember that sneaking that stuff in past us anyways is all fun and games, until your surgery is delayed because the risks of anesthesia are too great with your recent meal, so now you have to sit around and feel your appendix bursting, because the anesthesiologist isn't going to risk getting sued when you vomit during surgery, aspirate, and become a bigger brain-dead vegetable head than you were when you snuck the Monster Whopper with Fries down your gaping maw while waiting for the CT scan.

But please, do understand that if you keep pushing the point, eventually we'll realize you don't just have an abdominal problem, you also have the brain of a stegosaurus pulsing, peanut-like, somewhere inside your great empty cranial vault.

Patient Safety tip: we also frown on people laughing at sit-coms while they wait yet subsequently reporting that their pain is a "10 out of 10"; ditto if we had to wake you up to ask you how much it's troubling you. Imagine Wile E. Coyote, the boxful of knives and sharp objects, and the rock ledge he fell off of landing on your tenderest spot - if you're feeling that, and we walk in to see you doubled over, sweating, moaning, and writhing, we'll buy it. Otherwise, we'll write down your "10", then record "patient was in no distress, smiling and laughing" which is medical chartese for "horrible actor, terrible liar, and no Oscar nomination". Doubly so if you're "in pain" when we ask, but look just fine when we sneak a peek over your shoulder a minute later from the hallway (trust me, we do this a lot - thank the local drug seeking junkies); if that happens, you're so busted. Please, I beg you, don't be that guy. It's cold in Siberia, and mentally, everyone will banish you there.

If you do all this, you'll save us a lot of wasted effort, and yourself several extra wasted hours on what's liable to be a 2-4 hour process. Which, despite everyone's best intentions, still may fail to find a diagnosable condition or cause for your pain. Which doesn't mean you don't have anything, just that we can't tell you what it is, how to fix it, or when it will go away.

And a lot like the atypical chest pain patient, if we send you home, it means whatever it is isn't going to kill you imminently, even if you still think you're going to die.

The same is true for your child, and for the same reasons. When you get bored, fed up, or exasperated with the process, remember you came to us for a good reason, and we aren't kidding when we make you sign the AMA form, and list possible outcomes starting with "DEATH". We yell because we care.

But you may still need to follow up with a specialist, rather than come back here serially after refusing to do the follow up, because "the mystery pain is back". Which quote is how we'll soon lovingly refer to your return visit if you keep pulling this schtick without doing what you were told.

Live and learn.

1 comment:

  1. Out of all the things in this post that made me laugh because they're so true, the most amusing one to picture is that of a little stegosaurus brain rattling around. And then I stopped laughing, because this truth hurts.