East Timor Medical Elective - Week 4 (Part 3 / 6)

“ENRICO” (?CANCER METASTASES)

I knew I had a “short fuse”, but forgot to take my afternoon medication one day. I was trying to clerk a newly admitted patient called “Enrico”, who Dr. Dan noted had “Abdominal Pain” as his main complaint.

I think when I'm more tired or sleep-deprived (especially un-medicated), my mind seems to be more concrete, inflexible, and absent-minded, augmenting my desire to be very methodical.

I greeted Enrico and starting asking him about the Abdominal Pain, trying to cover “SOCRATES” (Site, Onset, Character, Radiation, Alleviating Factors, Time Course, Exacerbating Factors, Severity) before moving on to other questions.

I asked him if his Abdominal Pain spread to other parts of his body, he started talking about his headache and shoulder pain, and how it's so bad. Without realizing that his headache was important, I thought he was just going off on a tangent, or not understanding my question. I thought his shoulder pain was just a plain old Arthritis from his old age, and that his headache was the bread-and-butter variety. At the time, I thought that if Dr. Dan didn't write “Headache” or some other medical complaint in the mini-notes, then it couldn't be serious or worth focusing on.

I repeated again slowly in Tetum and gave examples of pain radiation, but then he kept talking about his headache, how it's so bad. I was still focusing on the Abdominal Pain and got increasingly annoyed at his diversion from my history taking. I think I actually asked the same question in various forms up to 5 times (in grammatically correct Tetum), but to little avail. In my spaced-out, disinhibited state, I thought he was trying to fool around with me and got a bit angry. The patient opposite Enrico's bed giggled from my visible frustration, and said I needed more patience.

It was a futile effort trying to get him to talk any more about the Abdominal Pain, so I just gave up on the history taking and physically examined him. He had Epigastric tenderness, so my differentials included Peptic Ulcer Disease and Pancreatitis (although that was unlikely).

Soon after, I presented my “incomplete” case to Karl, and he said that another differential diagnosis would be Stomach Cancer which has metastasized to his brain, causing a headache. He needed a CT-Brain at GVNH to rule out any CNS lesions.

OHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH.

I felt really guilty, that I got angry/annoyed at someone who didn't deserve it. It made sense now. Yes, his headache could very well be a sign of something much more sinister. I realized that there will be times where being too methodical is actually bad, and you need to know when to change your strategy. I also realized that Dr. Dan is also human and at times will miss things too, so I couldn't just depend on his mini-notes as the core stimuli for history taking. You need to focus on what the patient says themselves, expand on that, and attempt to fit the puzzle pieces together to formulate the relevant differentials. 

By dismissing what the patient says based on what other Drs say, it can sometimes impair your ability to find the right answer. At the very least, in Australia I'll be documenting to the best of my ability all of the patient complaints for Medico-Legal reasons, even if I secretly don't believe them.

Since this episode, I decided to take my afternoon medication routinely again to improve my alertness and cognition. I thought that I didn't need it coz I've “crashed” (sleep attacks etc) in the afternoon a lot less often than in Australia, but my cognitive impairments (especially after lunch) were still present even if I didn't fall asleep. I now also take Dr. Dan's mini-notes as a “partial hint”, but not a definitive summary of the patient's problems. At the end of the day, you need to know how to take a History and do a Physical Exam yourself, for the benefit/convenience of both you and the patient.