A history lesson

It was my first week of clerkship, and the first time I would interview a patient without anyone looking over my shoulder. I was primed for it. Earlier that morning at rounds the chief himself had given a mini-lecture on the doctor-patient relationship. He reminded us to put ourselves in our patients' position, with all their fears, anxieties and pain, and to listen with an open mind. He emphasized: "If you listen to your patients carefully, they will tell you what the problem is." FIGURE

So there I was, half an hour early, feeling quite confident in my newly washed and ironed white lab coat with extra pens in my pocket, just in case. The first patient was Mrs. G, a meticulously dressed and coiffed older lady with a heavy accent. She looked and sounded quite relieved after I introduced myself and sat down with her, ready to take the history.

She said: "Oh dear, I am so glad you are a lady doctor. I don't feel comfortable talking about this thing with a man ... you know how it is."

I didn't really know, but I gave her a friendly smile and reassured her that we were professionals and that she should not feel embarrassed about anything at all. "So what is the problem, Mrs. G?"

She started to fidget with her handbag and said in a low voice: "Well, you know dear, I ... well, how do you say it ... I have been dropping lately."

"You have been dropping lately." I repeated the sentence to buy time while a long list of differential diagnoses raced through my brain: TIA, stroke, seizures, brain tumour, hypoglycemia? Anemia? Cardiovascular something-or-other? What about metabolic disorders? And don't forget cancer ... It could be any of these for an elderly lady with new onset of "droppings." What an unusual way to describe falling - but I stuck with it for the rest of the interview. This was not the time to correct someone's vocabulary.

"So, how many episodes of dropping have you had, Mrs. G?"

"Oh, I had a few before, but lately I have them everyday."

"Every day? And have you ever injured yourself during any of these droppings? For example, have you hit your head against the furniture or the bathroom sink?"

She looked at me with surprise and said No.

"Has anyone witnessed any of these episodes?"

"God, no," she replied, with a look of horror on her face.

"And are you fully awake and alert during these episodes, remembering everything?"

"Of course."

"Do you ever get chest pain before or during an episode?"

"No, never."

"Headache, dizziness or visual disturbance?"

"No."

"How about weakness or numbness in your limbs?"

"No."

"Do you feel nauseated, sweaty or anxious before you drop?"

"Gosh, no." Although she looked perplexed by this line of questioning I had to get to the bottom of things. And so I continued.

"Have you ever lost bowel or bladder control during an episode?"

"No."

"Do you smoke, Mrs. G?"

"No, dear. My husband used to smoke but I never liked the habit"

"Have you lost any weight lately?"

"No, actually I might be a bit heavier since Christmas ... with the cooking and baking it is hard to stay thin."

"So you are pretty healthy otherwise?"

"Yes, I can't complain. I have a bit of back pain and my ankles swell up here and there but I have no complaints."

"No past history of heart disease?"

"No"

"Stroke or seizures?"

"No."

"Diabetes or high blood pressure?"

"No, dear."

I was getting to the end of my rope. I had absolutely no idea what was wrong with Mrs. G, and her surprised looks didn't help. I decided to try another strategy.

"Mrs. G, do you live alone?"

"Yes, since my husband died four years ago."

"And do you live in a house, or an apartment?"

"A house, dear."

"And is your house well lit?"

Now she looked at me as if I had just stepped out of a spaceship with two antennae sticking out of my head.

"Eh, well I guess it is, yes. Why do you ask?"

"I just want to figure out why you keep dropping like that."

Now she looked at me with her mouth open. She seemed ready to say something, but desisted.

I kept going.

"Do you have carpeting in your home, Mrs. G?"

"Yes."

At last, a yes. I knew I was getting close.

"And have you ever slipped on the loose carpet?"

"No, dear, the carpet is glued to the floor."

"Glued to the floor. I see. What medications do you use, Mrs. G."

"Oh, just the little white pills for the back pain and Metamucil for ... you know ..."

"Yes ..."

But I didn't know. I didn't have a clue what to think. I decided to give up the history and end with the usual, last-resort question.

"Is there anything else I should know before I examine you?"

I had a complete neurological and cardiovascular exam on the menu for her.

"Well ... now that you're asking ... You see, I think I'm getting worse. I ... well, before I used to drop but it would go back in by itself. Now I have to push it back."

I sat there in silence. I must have looked like I'd seen a ghost, for after a moment she leaned over to me and asked, "Are you okay, dear?"

"Eh ... yes ... yes I'm fine ... Please excuse me for a second ..."

I got up and grabbed the chart that had been sitting on the desk the whole time. The first line after the personal information read as follows.

"Reason for referral: RECTAL PROLAPSE."