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Spring 2014
BMM Current Issue
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Without a History
Musings on the vagaries of medicine.
In an ideal medical encounter, a patient gives a concise, relevant history of her symptoms, the physician performs a focused physical examination, and the differential diagnosis—a list of the likely disease processes at hand—is formulated. A few lab tests rule in or rule out suspected conditions, a working diagnosis is made, treatment is initiated, and healing ensues. Simple, quick, straightforward. And, at times, vastly unrealistic. The vagaries of this process remind us that medicine is seldom an absolute science.

There is a long-accepted truism that we can discern nearly 75 percent of a diagnosis through a detailed history and physical exam. But many patients simply cannot give a coherent history. Due to age, dementia, intoxication, delirium, or a combination of the above, histories can range from erratic to misleading to outright comical.

Ever the sleuths of human woe, we rely on the physical exam to narrow the expansive differential diagnosis for a nebulous yet frequently encountered ailment of, say, “altered mental status.” Altered mental status can result from a dizzying range of disease processes, from life threatening—meningitis, myocardial infarction, leptomeningeal carcinomatosis— to less worrisome maladies, such as mild dehydration or viral illness. Among the elderly, however, it seems an undercooked egg at the nursing home, a tiff with a family member, or a distressing Bingo outing can sufficiently perturb a patient to seek, or be sent for, medical evaluation. Additionally, between the nursing home, EMS, triage, emergency department and admitting physician, it is no wonder the patient is out of sorts and the history befuddled.

Divining a slightly incoherent narrative can reveal a delightful mash-up of facts. An elderly patient who was found on the ground recently informed a colleague she was in the hospital because someone “threw a pan of tomato sauce” at her. Was she hallucinating? Was she on the ground because of acute illness? Did she lose consciousness? Who was this hurler of marinara? In such situations the history is less a map and more a mélange of dead ends. Onward to the physical exam.

We can discern important diagnostic clues even if a patient is unable, when asked, to breathe deeply or to move an extremity in the neurologic exam. The patient’s fluent speech, lack of neck stiffness, and ability to move her extremities argue against many neurologic processes. But how to interpret the matted red material in her hair? Could it be blood, and possibly a harbinger of underlying subdural hematoma? Or simply marinara?

Having exhausted the two pillars of our diagnostic armamentarium—the history and physical exam—we must choose from a slew of tests and imaging studies. In med school, we learn about the pitfalls of tests ordered without the scaffold of clinical suspicion: false positives, false negatives, and incidentalomas can muddy the waters of clinical diagnosis. When a demented and delirious patient answers pointed questions incoherently, we cast a wider net to uncover the specific disorder. We order CT scans, chest x-rays, and more blood tests than we might with a more lucid patient.

In the end, we hope to find a discrete pathological process to treat, but often our work is more focused on ruling-out, rather than ruling-in, a diagnosis. It is difficult to treat a ruled-out diagnosis; hence, in addition to more tests, we provide intravenous fluids, oxygen, and empiric antibiotics. We cross our fingers and hope that we have effectively treated the relevant conditions. Our search for the elusive malady goes on.

Medicine’s occasionally erratic nature brings to mind Voltaire’s remark: “the art of medicine consists in amusing the patient while nature cures the disease.” But in these challenging cases, perhaps the art consists in embracing the vagaries of our work.

Sam Evans is a third-year resident in Brown’s internal medicine residency program.
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