The fine art of listening

Every patient has a story, and listening to it might just reveal a diagnosis.

It all started with a 56-year-old patient who came to the emergency department (ED) for abdominal pain. She was handed over to me for overnight observation after an initial examination. I looked through her chart before going into her room, but could not find anything remarkable. I took a detailed history, but all I discovered was that she had been seen 12 hours earlier in a neighboring hospital, and the workup—including basic labs and a CT of the abdomen—was unremarkable.

When I saw the patient, she was visibly uncomfortable, describing her pain as severe, diffuse and constant. After talking to her and her family, I planned to observe the patient overnight. Even her lactate test came back normal. Wondering what I may have missed, I realized I forgot to do a rectal exam—an omission I promptly corrected. Still no clues as to the cause of her pain. Puzzled, I consulted general surgery. The resident examined the patient and, after speaking to the surgery attending, ordered a repeat CT—which was again unremarkable.

Courtesy of Vishal Mundra
Courtesy of Vishal Mundra.

Throughout the night, the patient needed multiple pain medications. The next day, she was taken for diagnostic laparoscopy due to relentless pain. She was found to have ischemic bowel, and died five days later.

I wondered: Should she have been taken to the OR that night based on her symptoms? I was content that I had gone into her room multiple times the first night to check on her, and all her tests had come back unremarkable. But the question remained in my mind, and I resolved to listen harder to my patients.

Soon I encountered a 51-year-old female with an extensive history of opioid abuse, smoking and fibromyalgia. She came in for severe pain in her anterior shin and kept asking for stronger and more pain medications. She also complained of weak dorsiflexion in her right foot. Her creatine kinase (CK) was 2819 u/L. After an initial ED evaluation, I took over the case.

I had doubts about whether this patient had real symptoms. She had been seen in another facility the night before and was sent home after repeatedly requesting pain medications. Her medical record showed multiple opioid prescriptions had been filled in the past few weeks (which she denied repeatedly). Now, as my patient, she complained of severe pain on pressure and some weakness in her right leg. She denied any trauma. I examined her and indeed, she had a foot drop. Her pulses were good and her reflexes were absent bilaterally. I wondered about compartment syndrome but with no trauma and an extensive drug abuse history, I wasn't sure.

The orthopedic surgeon on call also was puzzled. Then the patient went to the restroom while I was sitting obscured in a corner of the physicians' lounge. I quietly showed the ED doctor that the patient was walking with a drop foot even though no one was looking at her. I realized there had to be something wrong. The next day, she had more tests done, including a CT angiography that was negative. Her compartment pressures were measured and were high at 38 mm Hg. She was taken for urgent fasciotomy, and the operative findings showed the muscles in the anterior compartment were gray and dead with no signs of infection. She was diagnosed with atraumatic compartment syndrome and had a good recovery of her function over the next few days. This felt like a victory, achieved in part by remaining open to the patient's complaints of pain, despite her history of drug abuse.

By now, I was listening more and paying attention to even finer details. A new patient came in at 6 a.m., after I had done a 13-hour night shift. When the ED physician said I had a 27-year-old female patient with a probable groin abscess (which he could not drain or see with ultrasound), I was not that keen to admit. All her labs looked unremarkable. I went to the patient's room and took her history. During her interview she said it felt like she had viral myositis. I groaned inwardly; there were no findings on exam suggestive of myositis. Still, I asked what she meant. She said, “My urine was dark that time too.”

I was skeptical but wondered how a layperson would know that urine can be dark in muscle breakdown. So I ordered a CK level just to prove it was normal and went home. When I came back, I checked her CK—and it was 65,126 u/L. I felt both shamefaced for being judgmental and skeptical, and good that I had paid attention to what she said.

These patients and many more have taught me a useful lesson. Yes, we all are pressed for time. But every patient has a story to tell and it's our responsibility to listen to them carefully. Sometimes the diagnosis is hidden in their words.