Family Webicine

By Rodney Moser, PA, PhD

My daughter ended up in the ER over the weekend. She was having severe pain in her left upper side, along with nausea. Suspecting that she may have inherited my kidney stones, I advised her to go to the ER so that she could get the proper work-up. Since she also had a fever, a kidney infection is another likely cause.

When medical providers sort out symptoms, the first and most important step is to LISTEN to the patient. If you listen carefully and long enough, the patient will usually reveal their diagnosis without much investigation. The history is the key.

Anatomy is the next factor. Knowing that her pain is in the left upper quadrant of the abdomen, below the ribs, there are only limited possibilities: First and foremost is the left kidney. It could be a stone or a kidney (not a bladder) infection. It could be the spleen or upper part of the intestine. Something as simple as constipation can cause gas to accumulate in this area (the spleen flexure), and cause pain. Lastly, it could be the ribs, muscles, or even nerves. Herpes zoster (shingles) can even start with some unusual, one-sided pain. Lobar pneumonia (the lower areas of the lungs) can occasionally cause pain in this area, but the lack of respiratory symptoms sort of ruled this out.

My daughter shows up at the ER, and after a few seconds (yes, seconds) of medical history, the doctor ordered a pelvic ultrasound, a pelvic exam, and pregnancy test. His working diagnosis was an ectopic pregnancy. This really freaked out my daughter since this was the anniversary of a miscarriage that she had several years ago. She uses effective contraception and has one partner, so unless she has a rogue ovary or Fallopian tube hiding up under her ribs, it would be highly unlikely that this was the cause of her pain. Of course, the (expensive) tests were normal.

An abdominal CT scan was ordered. No kidney stone. Blood and urine tests were ordered, but a urine culture takes at least two days. I am sure she had a CBC (blood count) and a bank of metabolic tests but no one gave her copies of the results. She left the ER several hours and thousands of dollars poorer with a diagnosis of “abdominal pain, cause undetermined.” Great, she knew that before she arrived. She was discharged on pain medications when they insisted that she probably “pulled a muscle” in her chest wall. Since it did not hurt to move her chest wall, she was rightfully skeptical. She was advised to be seen by her primary care doctor on Monday.

Still in pain, even on pain medications, she was able to get an appointment on Monday, but with a different physician, not her regular provider. Rarely looking up from her computer, the doctor ordered a gall bladder test (for those who are familiar with the location of the gall bladder; it is on the right side) and some liver function tests (the liver is also on the right).

Maybe the doctor was confused or missed that day in anatomy class? Since the ER did not forward the test results as requested, she re-ordered them (more money), including another urine culture. She told my daughter to keep taking the pain medication and use a heating pad. My daughter continued to have a low-grade fever — a sign of infection. No one seemed to care since the fever was not high.

Two more days later, the second urine culture revealed that she had did have a severe kidney infection. Antibiotics were called in to the pharmacy. Hopefully, my daughter will not have an allergic reaction since I am allergic to this particular antibiotic. No one really asked her allergy history.

Caring for patients first requires that you care. ER physicians often are so overwhelmed by the number of patients that need to been seen they develop this “treat ‘em and street ‘em” mentality. Run in, take a quick history — even skip the exam completely, and order LOTS of tests. Tests take time. This allows them to see other patients while someone else collects this plethora of expensive, and often unnecessary, medical information. Several hours later, armed with the results, they make a diagnosis based solely on the diagnostic tests that were ordered.

In my daughter’s case, at least half of the tests that were done were not clinically necessary. She was misdiagnosed based on what she “didn’t have” and no one really seemed to care what she did have. The physician even hinted that she may have been having a stress reaction.

Her primary care doctor has a history of caring, but unfortunately, she had to see a different medical provider — one that did not give the impression that she cared. She was finally diagnosed and appropriately treated, but it took four days, thousands of dollars, and two different medical providers to get an answer.

Where is Marcus Welby, MD when we need him?