when to think outside the box

Last week I talked about the history of the present illness, or more appropriately, the story of the present illness. This cannot be adequately recorded using a bulleted list of oversimplified prompts (What are your symptoms? When did they start? How often do they occur? How long do they last? What kind of treatment have you tried?). The story also needs to take into consideration the patient’s expectations for recovery, his fears, the misconceptions he may have about his illness, and the effect it may have on his family and friends, his ability to work and his willingness or reluctance to engage in treatment.

As if that weren’t hard enough, the standard medical record goes on to explore three other histories that influence the patient’s illness:

1. THE PAST MEDICAL HISTORY (PMH):

Here the provider is looking for a history of previous illnesses, surgery or injuries that might have led to the patient’s present illness or have predisposed him to problems later on. Perhaps he was treated for a childhood cancer that increased his risk for a second malignancy later in life. Maybe it was an accident that required surgery for abdominal trauma that predisposed him to the occurrence of a bowel obstruction later on. Maybe a case of rheumatic fever as a child damaged a valve in his heart leading to heart failure years later. The possibilities are endless.

The past medical story may sound a little different, though. In my brother’s case (see my previous posts), he suffered bouts of anxiety and depression all his life but no one understood why. He was ashamed to tell his story so no one could help him. It didn’t seem possible that his anxiety and depression had anything to do with the episode of rheumatic fever he experienced when he was five years-old. Not until he told me about the fear, dread, and hopelessness he suffered way back then did we uncover the truth together…that, as a child, he misunderstood what was happening. He was sure he was going to die, and the fear of death had stalked him all his life. Once he understood the disease and how it was treated back then, once he accepted the fact that his heart was healthy, recovery from the emotional and psychological aftermath of the illness was possible.

2. THE FAMILY HISTORY (FH):

This is important for the provider to explore because some conditions tend to run in families. Some problems are passed on from generation to generation. Genetic disorders come to mind, but so should alcoholism, certain cancers, and some mental health problems. Their occurrence in a relative may raise the risk for other members of the family.

The family story, though, may be more complicated. In her landmark book “Narrative Medicine—Honoring the Stories of Illness,”

...Rita Charon sites a patient who presented with abdominal pain, weight loss and diarrhea. Because his uncle had died of pancreatic cancer he assumed he had the same thing and he believed that death was imminent. Having watched his uncle suffer through the terminal stages of the disease, the patient chose to die of it as quickly as possible. What surprised him was the ease with which he made this decision and how complacent he was about the end of his life. When testing revealed a benign and easily treatable condition, he was forced to confront his masked depression and passive suicidality.

3. THE SOCIAL HISTORY (SH):  

Here the provider is looking for a history of smoking, drug and alcohol abuse, dietary habits, exercise, domestic violence, sexual preferences and habits, and occupation, all of which can adversely affect the patient’s health.

This is where the patient’s story gets complicated. He may be ashamed to admit to unhealthy habits and practices. He may feel guilty if his health has suffered because of them. He may lie about it. For these reasons, it may be harder to pull this part of the history out of the patient, and even harder to motivate him to change.

I had been seeing a patient for years, trying unsuccessfully to lower her triglyceride levels. We discussed her diet and exercise routine in detail at every office visit. Even medication didn't help. It was a mystery until she admitted to consuming a bag of chocolate chips every day.

Every. Day.

I was flabbergasted. Had she failed to make the connection? Was she in denial? The truth can sometimes be hard to come by.

It’s a monumental task just to take a good medical history. Then you still have to conduct the physical examination, order tests and create a treatment plan. And that takes time.

Nowadays, for speed and convenience, the medical record allows the provider to simply click on a little box next to the problem:

                                                          tobacco use

       alcohol use

       illicit drug use

       caffeine intake

But this doesn’t give you the real picture. Sometimes you have to think outside those little boxes and color outside the familiar lines to get the patient's whole story.

*

“It is more important to know what patient has the disease

than to know what disease the patient has.”

~William Osler~

 jan