Where Does it Hurt?

“Noncardiac Chest Pain” was Laurie Black’s discharge diagnosis. Her chest CT Angiogram didn’t show a pulmonary embolus, her troponins were negative for a heart attack and her nuclear stress test was negative for coronary ischemia.

“So what do you think it was?”, she asked while I read through her hospital discharge summary.

“I don’t know…show me where the pain was”, I answered.

“It started in my back, on the left side, and then it went up and around to the front and then down my left arm and my hand felt kind of tingly.”

“Where in your back, upper or lower?”


I palpated her left trapezius and put some pressure between her spine and her scapula.

“I assume the doctors at the hospital did all kinds of poking and prodding here”, I asked.

“No, I don’t think anybody really touched me”, Laurie answered.

“Can you move your shoulders around a bit”, I asked as I pushed my fingers in a little harder.

“That’s very sore”, she said, and I could feel the tightness in her muscle.

I moved to her front and asked her to show me the range of motion in her neck. It seemed close to normal.

“Try to go a little further”, I said.

“Ouch, I just felt something, in my arm”, she startled.

“Looks like it’s all coming from your neck. How about that…”

Just a few days earlier I had another “aha” moment, this one regarding a patient with abdominal pain.

Nora Friedman had seen one of my colleagues with a one month history of a painful lump in her right lower abdomen. She ended up with both a CT scan and an ultrasound, and the only abnormality they showed was a very large cyst in the lower portion of her right kidney. The radiologists suggested this cyst could be drained in order to relieve her pain. That’s where I came into the picture and as she is on blood thinners, I ended up fussing with the management of her anticoagulants before and after the procedure.

When I saw her after it was done, she told me that her pain hadn’t changed at all.

“Show me where it hurts”, I asked her.

“Here”, she said and laid her hand across her abdomen near McBurney’s point.

I asked her to lie down. She did and I felt nothing.

“I actually feel it more when I stand up”, she offered.

As she stood in front of me and I placed my hand where she directed me, I asked her to cough. Suddenly I felt a soft, almost squishy protrusion under my fingers.

I called the interventional radiologist who had aspirated her renal cyst through a long needle in her back.

He confirmed that her cyst wasn’t likely to have reaccumulated that quickly and I told him that both she and I thought we felt a hernia when she stood up and coughed.

“I’m looking at her CT right now…”

His voice trailed and there was a long silence.

“Actually, I can see a spigelian hernia now. That would explain everything. She needs to see a surgeon.”

So, in hindsight, a more carful examination of the patient at our end, and of the images at the radiology end, could have saved Nora an invasive procedure, just like Laurie could have been spared some of her fancy hospital tests for what turned out to be a simple neck problem instead of a cardiovascular emergency.

4 Responses to “Where Does it Hurt?”

  1. 1 Giada June 9, 2017 at 12:25 pm

    great post. went to the gastro last week. she was running over an hour late. I couldn’t get a word in. will need to find another. such a waste of my time and $$.

  2. 2 Mary Ellen McColl June 9, 2017 at 3:03 pm

    I repeatedly hear that no one previously did a physical exam on a patient seen for a conundrum which is just as frequently identified as you have noted with an adequate exam.

  3. 3 Daniel D O'Clair June 9, 2017 at 7:30 pm

    As a clinically trained, licensed massage therapist I see many clients who have been to doctors that never performed any physical examination. Countless procedures and misdiagnoses could be prevented with a few unhurried minutes of skillful palpation. Thanks for another great post. I love that you are so candid with showing your humanity.

  4. 4 Julia June 18, 2017 at 12:50 am

    I completely agree with the above comments on the lack of a hands on physical exam. I am a home health nurse & went to see a gentleman who had been in the hospital for abdominal pain which he still had. When I touched his belly to hear bowel sounds, I felt a thrill & could hear a very large bruit. Apparently, no one bothered to do a quick assessment to rule out a AAA. He refused to return to the hospital with the expected results.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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