Archive for the 'Progress Notes' Category

The Art of Listening: A Not-So-Simple UTI

Many clinics allow the practice of ordering antibiotics for women who claim to have symptoms of a urinary tract infection. In some cases patients bring in a sample, and in some they produce the sample in the clinic in a free “Nurse Visit”. The doctor is then expected to prescribe without evaluating the patient.

The only provider on duty one Saturday this fall, I was asked to do just that. I asked the medical assistant: “Exactly what are the symptoms and is this a patient who gets UTIs all the time?”

“Doesn’t look like it, she’s only been seen once before and that was over a year ago.”

“Gotta be seen, just double book her”, I said.

The woman was in her fifties, came in as a new patient a little over a year ago. She had a history of colon cancer and was behind on her followup colonoscopy surveillance. In that one and only visit she expressed some hesitation about getting that done because she was new in town. She wanted to think about it. She did agree to getting a mammogram scheduled, and she agreed to get some basic bloodwork – but never did. From what I could tell, the mammogram was actually never done.

Her urine had a trace of leukocytes, white blood cells, and a trace of blood, both common findings even in healthy women.

“What kind of symptoms do you have?” I asked.

“I’ve got this pressure but I don’t always go very much.”

“How long has that been?”

“About three weeks now.”

“Does it burn or sting when you go?”

“Only sometimes.”

“Do you get urinary infections often?”

“I’ve only had one in my life”, was her answer.

On exam, she was a little tender over her bladder and deep to the left, but her belly was soft and I couldn’t feel anything suspicious.

I pointed out that she had hesitated about Dr. Grogan scheduling a colonoscopy. She said she had thought that was going to happen but she never heard back.

I showed her his chart entry and explained:

“Your symptoms may or may not be from an infection. I’ll start an antibiotic for you but whether a culture shows anything or not, you’re due for your colonoscopy and you may even need a CT scan if that tenderness in your belly doesn’t go away. For that reason I really suggest we get that bloodwork going, because the CT scan would require contrast. So my suggestion is, take the antibiotic, get the bloodwork and see doctor Grogan to follow up on your symptoms.”

I messaged the receptionist to make a followup appointment and we wrapped up the visit.

A prescription for an antibiotic without a visit could have had tragic consequences. I don’t believe in accepting a patient’s self diagnosis without double checking it. I also don’t believe in prescribing without taking a look at the bigger context of the most apparent presenting symptom.

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.

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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