By the Way of the Door

“By the way”, as we are leaving the exam room, “I just wish my headache was not so much worse with coughing.” Brain stem mass.
“No doc, not in this part of the neck. I mean the swelling is here.” Lung cancer with supraclavicular node.
“Do you ever get a song in your head, you just cannot stop hearing.” Temporal lobe epilepsy.

The “by the way”, typically as we’re leaving the exam room, is a universal primary care daily experience. Weeding through the myriad of “by the ways” to pick out the uncommon or rare, hair-raising, sentinel finding seems an impossible task. But, over multiple encounters in successive years, primary care built clinical relationships help to hone the alarm system to fire when random clues arise that are discrepant with a patient’s established history. As long as I listen.

There lies the rub in the Emergency Department. No prior relationship, or worse a pigeon-holed prior relationship. Limited time to listen. Frequent redirection. Interruptions. Early boxing of histories into the chronic headache or low back pain container, or the multiple other reflexive responses to similar histories. Insufficient provider processing of histories recorded by scribes. Fatigue, especially towards shift end, especially over-night.

I have more reminders of bad acting illness in the emergency department. Looking for head bleed, abdominal mass, ectopic pregnancy, myocardial infarction has a high daily yield in the ED. So you memorize common pitfalls, decision trees. There is less gestalt and more guidelines, more decision-rule calculators. More advanced imaging and testing. But the history drives everything, and no abdominal CT will catch the CNS mass causing intractable vomiting.

Dr Mark Jaben “ranted” about this in EM:Rap – Talk to your patients.. His “rant” can be summarized in one word: Listen.

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