Thursday, January 06, 2005

Okay, So I'm Not Sherlock Holmes!

During their education medical students learn the proper way to interview patients, in order to obtain crucial information that pertains to the problem at hand. As those of you in the health care field know, this process is called obtaining the History, which has seven standard parts. They are to be documented in the chart, usually in the following order:

Present illness (a narrative of symptoms)
Allergies
Medications
Past Medical History
Family History
Social History
Review of Systems

We were all taught in school to do a thorough job taking a history, for often embedded within this morass of information are clues that will lead us toward the correct diagnosis. Unfortunately many doctors develop a rather cavalier attitude about the history as they ripen in their careers. Taking a history is tedious, and if the interviewee should look upon this occasion as a invitation to dictate their life story, the doctor will soon decide that the fewer the questions asked, the faster he can get out of the room and on to the next crisis. Shortcuts are found, such as copying the answers recorded by the admitting nurse. Eventually whole sections of the history are skipped in the name of conservation of energy. Such time-saving maneuvers seem to be a neat trick but I believe that one is always better off to put the deerstalker cap on, pull up a chair and listen to the patient's story - for sometimes one small detail can solve the Mystery of the Dyspneic Man.

I was reminded of the importance of taking a complete history by the following case, in which a patient was diagnosed with a malignant mesothelioma without any apparent exposure to asbestos. As you know, asbestos exposure is essential for the development of the cancer. Just for fun, let me present a few details to you and then see if you can figure out what I forgot to ask. I might add that once the key piece of information was revealed I felt like an idiot for not thinking of it, as it immediately answered the question as to where he was exposed to the deadly mineral.

Here are the clues:

The patient is a 60 year old man with a pleural-based mass, a large mediastinal mass and a pleural effusion. Biopsy of the pleural mass revealed mesothelioma.

He has a history of smoking. He works as an manager for a construction firm but does not visit construction sites until they are finished - denying any exposure to asbestos through his job.

He denies helping with any demolition of a friend's house, or working in the railroad as a teenager, or living in a home where asbestos was present or brought home on work clothes. He simply cannot think of any time in his life when he was around such materials that could contain asbestos, and I was stumped at the end of our interview.

One week later, he volunteered a new piece of evidence about his past.

Upon hearing this new tidbit I slapped my head and cried "Come Watson, come, the game is afoot!," lit my pipe and stepped out of 221b Baker St. into the dense fog.

If you would like to guess what part of Mr. Dyspneic's past I forgot to query, feel free to comment below. I'll be happy to pay homage to the first correct answer!

1/7/05 Addendum: answer is posted in comment section.


40 Comments:

At 10:06 PM, Blogger Caltechgirl said...

His office? I thought of this because half the dental school at UNC is taped off right now....

 
At 10:31 PM, Blogger Allen said...

Well, the best flea question for fascinomas is "what pets do you have", but I cannot think of any asbestos-containing pet.

I would ask him about his hobbies, specifically, does he do his own brake work? There's a decent source of exposure.

GruntDoc

 
At 11:36 PM, Blogger Dr. Craig Hildreth said...

To the above sleuths:

No, the office was not contaminated.

No, he didn't win an asbestos-laced dog at the county fair.

Grunt Doc: thanks for linking to me. If working on brakes can cause mesothelioma I've got nothing to worry about! He doesn't, however, work on cars.

 
At 12:09 AM, Blogger mrlmd said...

When did he serve in the Navy? (most likely in a shipyard, classic asbestos exposure)

 
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To where has he traveled within the past 5-10 years? Has he been to Manhattan or Oklahoma City?

 
At 5:36 PM, Blogger Dr. Craig Hildreth said...

mrlmd was right - the patient served on a Navy ship from 1960-1962, working in the engine room. This case is a reminder for doctors to ask about prior military service when completing the social history.

 
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