Old School Medicine

Much of modern medicine now relies on tests. When someone comes into the ER they almost always get blood work to one degree or another and then if the diagnosis isn't clear, they get some imagining (CT scan, Ultrasound, etc). Often the physical exam portion of the interactions is perfunctory and really only done for billing reasons. That being said, there are some times when something on the physical exam is more important than imaging and blood work.

I had a patient come in to the ER the other night and we were called down to admit her to the hospital for abdominal pain. Abdominal pain is really difficult to work with because there are some many causes for it. You have the pancreas, stomach, small intestines, large intestines, liver, gall bladder, and appendix. If you're a woman then you also have the ovaries and uterus as well as pregnancy that could be involved in the list of things we need to look at. This lady was a 22 year old lady who was pregnant, had a previous C-section (meaning she had abdominal scarring added to the list), and had a previous umbilical hernia (more scarring). Added to the mix is that she lives at the Salvation Army with her husband and child, is adopted from Vietnam and still speaks with an accent. She has been seen a LOT of times in the last year by both the ER, Obstetrics, and our Residency Clinic.

Anyway, I get down to the ER and start talking to her. She has a very very strange style of interaction. She would just sit there and look straight ahead and mumble answers. Her husband would answer some of the questions, but she just wouldn't make eye contact and just gave off a weird vibe. But one thing I learned from my public speaking class is that people are very uncomfortable with silence. So I would ask her a question and then just wait for her to answer. 30-40 seconds doesn't sounds like a long time, but try sitting in a small room at 10:30PM staring face to face with a doctor answering questions and it becomes a very long time. After a couple of questions and some very long pauses she eventually broke down and started talking with me. Essentially she has had this pain prior to her C-section and Hernia repair (hence not scar tissue, and the duration points away from it being her organs as they usually present more acutely) and although heating pads have helped somewhat, mostly just not using her abdomen has been the most helpful. She said it was worse with movement. All of her lab work was perfectly normal as was her baby.

Still confusing.

However, on physical exam I had her lie down on her back and then do a straight leg lift while I tried to push her feet down. This was very painful for her and perfectly elicited the pain she has been complaining about. Eureka! My conclusion was that it was some abdominal muscle strain that hasn't resolved because she has continued to use it with her job. She needs some Physical Therapy and a little bit of strengthening exercises and she should be good to go.

Most of what I do that is particularly memorable usually involves some sort of tragedy. It was really nice to finally do some sleuthing that changed course from what could have been a big work-up and potential surgery to something simple and easily fixable all because of a simple physical exam.