Adrian Bell didn’t look dehydrated, but his diarrhea had come and gone for a week and a half when I saw him a few weeks ago.
“Is anyone else sick with the same thing?” I asked, beginning my usual line of questioning.
“No”, answered Eleanor, his wife.
“Have you had any water to drink from a new or unknown source, or have you traveled away from home?”
“No”, both answered in unison.
“Any new foods that only you ate or that you don’t normally eat? Are you a big milk drinker?” I added, thinking about secondary lactose intolerance.
Still, negative answers.
“Any chills, fever, belly pain…” my questioning continued.
Nothing.
“Have you had any antibiotics prescribed by any other doctor?” I asked, because we have had a flurry of Clostridium Difficile infections in our community, which is something we didn’t have to worry about years ago. We had three cases recently at the nursing home, where Eleanor volunteers.
Still, “no”.
“Anything else going on, even if it seems unrelated?” I finished my questioning as I motioned for Adrian to get up on the exam table.
“I have had some joint pains”, he answered.
After an unremarkable physical exam, I ordered some lab tests, including inflammatory markers, a stool culture and C. Difficile test. I gave dietary instructions and we set up a follow-up appointment for a few days later.
At his follow-up visit, everything was the same and all the tests were normal. I sighed internally.
“Do you think it may be Beaver Fever?” Adrian and Eleanor both leaned towards me. “We’ve heard of an awful lot of people downstate who’ve had that.”
“I haven’t seen a case of giardiasis around here in years. How do you think you may have gotten that?”
“Well, two weeks before this started, I fell in a beaver pond in the woods in back of our property. I was checking out an old four wheeler trail….”
“Fell in a beaver pond…” I kicked myself for not having ordered a test for ova and parasites, but, of course, they can be unreliable.
“I think we’ve got to put you on some medication and do another stool test”, I said, thinking to myself that I now have one more question for future diarrhea assessments.
Medicine is like twenty questions sometimes. If you don’t ask the right questions, you don’t get the right answers.
A Country Doctor Writes: 
Or you do a long and thorough intake, ask for tests, suggest what to do, etc. and then as the patient is about to leave and standing by the door he/she says ‘oh, I forgot to tell you that …’.
Very well done. Do you allow any reprints?
Mike C
Reblogs with link to the site of origin are ok with me and most bloggers. Many of my posts are reblogged on KevinMD.com, thehealthcareblog.com, an Australian site, ruraldoc.com.au etc.
Let me ask you this – did you learn from the experience? That’s what matters. Fabulous post though. I need to show this to some docs and former docs.
It’s a great thing to learn from experience, bravo! Asking a series of specific, closed-ended questions, however, is risky: what if you don’t happen upon the “correct” question that lets you solve the mystery? Fortunately, there is a way to avoid this risk: ask open-ended questions. It is perfectly valid to ask what the patient believes is the source of the problem. In this case, a few well-chosen open-ended questions at the first interview would have provided valuable clues.
In this case the patient had no initial suspicion. His thoughts about beaver fever were the result of conversations he had after our first visit. Your point is well taken and my message in this post is that you can never think of every possible yes-or-no question. Many of the posts on this blog are about listening, for example “Starting Over”.