The Art of Listening: Cause and Effect

Sumner Finch is an 80-year old man of few words. He had gone to the emergency room three or four times for constipation but his belly was never tender and his abdominal CT scans always looked benign. The ER doctors were a bit puzzled and so was I when I first saw him for the same thing. He relied on various over the counter laxatives whenever he hadn’t had a bowel movement for two days in a row.

I prescribed a low, steady dose of lactulose, a type of sugary syrup that isn’t absorbed but stimulates the colon in a gentle way (just like many people get loose bowels on common sugar substitutes). He told me this just gave him gas.

I gave him samples of a fancy new medicine for idiopathic constipation. It cleaned him out but he said it then stopped working.

We looked at his medications. He was taking a high dose of an old fashioned calcium channel blocker for his blood pressure. This drug is known to cause constipation. I reduced his dose and his blood pressure did not go up, but he told me he was still constipated.

Every time I saw him his abdomen was soft and nontender.

“Did you ever have a bowel movement every day?” I asked.

“No”, he answered without hesitation.

“So, help me understand, why are you so bothered now if you don’t go every day?” I asked.

“Because when I don’t go, I wake up at night.”

“Why is that?”

“Because of my breathing”, he quipped.

“Tell me more.” I was puzzled.

“When my belly is full, I have to sit on the bed so I can breathe.” He sounded like that was obvious and nobody understood him.

“How long has that been?”

“About six months”, he answered without hesitation.

I repeated back to him what I had understood: “If your belly gets even a little bit distended, it makes it harder for you to breathe lying down.”

“That’s right”, he said.

“But that didn’t happen until six months ago. So I think your heart has changed. I’d like to get an echo to see if it isn’t pumping right. In the meantime, I’d like to give you a fluid pill to help it pump better. Will you try it and see if it helps your problem?”

He agreed, and by the time we sat down to review his only slightly abnormal echocardiogram, he was sleeping through the night. And he didn’t really care how often he moved his bowels.

Instead of complaining about his shortness of breath, he had asked me and the ER doctors for help in eliminating the obvious trigger. He presented us with a succinct cause for his troubles and we fumbled to understand the more ominous cardiac effect of even such a mild case of constipation.

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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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