Past history

Seated in an assessment bay, 58-year-old Christine (name changed) looks well. In fact, when she walked into the room, she did so with a quick step and a smile, although somewhat forced. I introduce myself and ask how she’s doing, and she starts with, “better than I was about an hour ago.” She’d arrived by ambulance because of pain in her stomach, a complaint with which she’d presented here two weeks earlier. The nurses off-loaded her from a stretcher and directed her to our waiting room, where she’d waited a little over an hour before seeing me.After 20 years in the ER, I have a routine from which I rarely stray. Sometimes, if the complaint is very minor—stubbed toe, superficial laceration—I may skip a step or two, but even in these cases I often dig a little before walking into the room.First, I look at the patient’s chart and scan the name, age, vital signs and presenting complaint. Christine’s complaint is “abdo pain,” something I’ll see several times every shift. Sometimes, the presenting complaint is vague (“emergency,” or “no complaint”), sometimes it’s worrisome (“drowning,” or “unresponsive”) and sometimes it’s funny (“bulging dick”). The last one was an honest mistake, a typo; it should have said “disc.”I turn the page and look at the short history taken at triage: Christine’s complaint in their own words. Christine’s pain is central, in the middle of her abdomen, and it feels like there is a ball whenever she eats. Sometimes, after a meal, her pain is unbearable and because of this, her appetite has disappeared. Although there’s been no vomiting, she’s had diarrhea for months, and in the last month, she’s lost about 20 pounds.The earlier visitThe next thing I do is look into our hospital’s electronic record system to see if my patient had any previous visits. The best source of information is a consultation note or a discharge summary, but Christine’s never been admitted here. She had similar complaints when she visited two weeks ago. She complained of food “getting stuck” when she swallowed, and weight loss of about 15 pounds over a six-week period. When asked by my colleague, she denied any previous medical problems, reported no medications other than an antacid, and admitted to smoking a half-pack of cigarettes daily with very little alcohol intake.During that visit, she’d been examined, had blood work and an ultrasound. My colleague found nothing on exam. “Abdomen soft, non-tender, no masses,” is what’s documented, likely canned text for a normal exam. The ultrasound was nonspecific but abnormal. While the organs (liver, spleen, kidneys) were fine, there was a small amount of ascites and trace bilateral pleural effusions. And her blood work was normal except for one thing: a markedly elevated alkaline phosphatase. Because she smoked, my colleague was suspicious for an esophageal mass. He faxed a referral to a gastroenterologist for endoscopy and let her go home.Before her visit two weeks earlier, Christine had only been to our hospital twice in the past six years, once for the flu and once for a sprained wrist. Indeed, it seems that before these past few weeks of stomach upset, she’d been healthy. Most often, I stop here, notes scribbled on the chart and go see my patient.But Christine is almost 60, and she might have medical history elsewhere, so I plug into the provincial network where I can find records from other hospitals. Ten years earlier, she’d had breast cancer and had undergone a right radical mastectomy as well as chemotherapy. Two years after reconstruction, she’d developed a local recurrence of her malignancy in the soft tissue that remained. She’d had a wide excision, and completed a course of radiation therapy. Since then, there are annual progress notes confirming that after the recurrence, she’s been clear.“I’m glad you’re feeling better now,” I say to Christine, “but what brought you in initially?” She tells me about her recent visit, which I’ve already researched. “I still can’t catch a breath or eat,” she says. “When I do eat, it just sits in my stomach.” She denies vomiting, but tells me that when she has bowel movements, it’s usually diarrhea. “The doctor I saw set me up to have an endoscopy to rule out a blockage in my esophagus, but it’s just getting worse and I don’t even have an appointment to see the specialist yet.”I ask the questions my colleague asked at her previous visit. I deliberately ask as my colleague might have: “Do you have any medical problems?” She says no. “So you’ve been healthy up until this?”She nods yes, and just as I’m about to ask if she’s had surgery in the past, she tells me she’s had breast cancer, but she’s clear.“I did see that,” I say. “And you had a local recurrence as well.”“Yes.”Perhaps this is why insurance forms list every possible medical issue one by one: “Do you have high blood pressure? Do you have heart disease? Do you have kidney disease? Have you ever had cancer?”Physical examI finish taking a history and proceed to physical exam. She looks well. Her heart sounds are normal, but there is decreased air entry to her right lung. She lies flat and I examine her abdomen. Like my colleague two weeks earlier, I can’t find any tenderness, but knowing her full story, I take my time and palpate all four quadrants thoroughly.In medical school, a preceptor once asked me to name the greatest risk factor for a blood clot.I’m going to nail this one, I thought, as I’d recently studied Virchow’s Triad. “You mean the three most common risk factors?”“No, the most significant risk factor.”While I tried to decide between the three, trauma, stasis and hypercoagulability, he said, “This isn’t a trick, what’s the greatest risk factor?”“Are you talking about Virchow’s Triad?” I said.He shook his head vigorously. He was a good teacher, but patience wasn’t his strength. “What’s the most significant risk factor for any condition?” he said, practically yelling. He answered the question before I could. “The most significant risk factor for a condition is having had the same condition previously. The most significant risk factor for a blood clot is a previous thrombosis. The most significant risk factor for a heart attack is a previous MI. The most significant risk factor for cancer is having had cancer in the past!”“What’s this?” I say, pinching a firm lump in the soft tissue of Christine’s abdomen.“I don’t know,” she says. “It’s been there for a while. It’s sore when I touch it.”“Have you had it looked at before?”“No,” she says.She sits up. “I’m going to repeat your blood work,” I say, “and I’m going to get a CT scan.” I’m honest with her. “I don’t like any of this,” I say. “That you’ve had cancer in the past, and that the ultrasound showed fluid in your abdomen, albeit trace amounts and that there’s this firm lump in your abdomen. I don’t like any of it.”“I know,” she says.I don’t even mention the elevated alkaline phosphatase. In someone with a history of breast cancer, no matter how remote, the first thing that comes to mind is bony metastases. And I’m sure, had my colleague known about her breast cancer, he would have come to the same conclusion. On the requisition for her scan, I make my suspicion clear. “History of breast cancer and recurrence. Progressive dysphasia, indigestion, weight loss, increased alkaline phosphatase, all suggestive of recurrent malignancy.”Hours later, the results are back. She has a massive right pleural effusion, likely malignant. She has abdominal ascites and peritoneal carcinomatosis. She has a right lung nodule. And she has extensive bony metastases involving most of her thoracic spine.She was admitted to hospital and diagnosed with stage IV incurable disease with the goal of controlling her cancer, not curing it.I told my colleague about this case, and he was disappointed that he didn’t pick up on the extent of her illness at her first visit. He was also miffed about why she didn’t mention her previous history of breast cancer. It was the most significant medical episode of her life and it happened twice. But for whatever reason, she didn’t tell the paramedics, she didn’t tell triage, she didn’t tell her attending nurse and she didn’t tell him.Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 20 years of medical practice all over Ontario.

Past history

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