An Old Lady Who Misled Me

Sunday, June 16, 2013 by aiyqosim

السلام عليكم ورحمة الله
الحمد لله رب العالمين و الصلاة و السلام على سيدنا محمد و على آله و صحبه و سلم

1. Lastweek, I got the chance to take history from one of a patient in one of the General Surgery Department. She was a 67 year old widow from Masr El-Qadeem, came complaining of painful legs.

2. At a glance, it was obvious that she is obese with several co-morbidities. She was an uncontrolled diabetic. She was sitting on wheelchair and looked stressed with the pain. I could see some obvious clinical findings even before I started asking her questions, yet I ignored it.

3. It seemed that her most distressing symptom was painful leg, so I decided to take her as "painful lower limb" case. I started assessing the complain, the present history, and excluding the possible differentials.

4. It couldn't be a case of limb ischaemia as the condition started acutely after she fell on the floor by inability to walk on her lower limbs, and before the minor trauma, she had no claudication pain at all. It couldn't be caused by any other common local causes. No signs of DVT, the skin was clean from any ulcer or pigmentation, no swelling, no redness, temperature was normal, no nothing.

5. She said something that sounds like 'fracture' in Arabic, but I thought it was irrelevant, or the patient was just misinterpreting (or exeggerating) her painful limbs.

6. Just after analysing the history of present illness (which I took it as painful lower limb case), Doctor Shareef came in. 10 minutes suppose to be sufficient enough to put a provisional diagnosis, yet I stucked still at the history of present illness.

7. To cut it short, Dr. Shareef asked few questions and.... "voila"! That was it. Unbelievably, the patient actually has recurrence of breast cancer in her right breast and bone metastasis.

8. Yup, the painful legs was due to pathological fractures of few bones of her left lower limb, and bone metastasis in her lumbar vertebra, compressing the sciatic nerve. Good job to myself! I've ignored obvious hirsutism that the patient had on her face. And the patient had done radical mastectomy for her left breast 4 years before. And the hirsutism could be due to the chemotherapy or hormonal therapy (tamoxifen). I was too slow in my history taking.

9. I know that nobody's perfect. But it's all about practice. Practice makes perfect. Good history taking needs sufficient basic knowledge and effective communication. I haven't read enough literature, and I haven't communicate well. Effective communication is a skill that needs practice.

10. Few things that I've learnt from this patient are;

- Patient doesn't come to you with label, "examine my left leg" for example. You have to figure out the problem.
- The most distressing complain of the patient is not necessarily the worst underlying problem he/she has. The underlying cause might be fatal, while the complain might well be benign.
- Communication skill is crucial, especially when dealing with foreigners, in my case, Egyptian.

11. May Allah guide us in the journey to becoming professional competent doctors. We have 4 months and a half till final exam. May Allah ease.

والحمد لله رب العالمين
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