What They Don't Say Could Hurt You
By K. Jeffrey Miller, DC, MBA
I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar.Cases I am preparing to present reminded me of how often this problem occurs and how difficult it can make our jobs. In this account, I will describe a few sample cases to illustrate the problem. Radiographs accompany the first two cases.
Case #1: The Fighter
The first case involves a male patient, 33 years of age. He entered my office with a chief complaint of neck pain. The pain had been present for a few days. He offered no explanation regarding the onset of the problem and was evasive when questioned regarding the origin.
On observation the patient was in obvious pain, experiencing spasm and cervical range of motion was almost nonexistent. His face was scraped and bruised, and his lower lip was swollen. Cervical orthopedic tests were negative, but the movements associated with their performance enhanced the patient's spasms. Joint fixations were noted in the upper cervical region.
When I told the patient X-rays were indicated, he resisted and asked, "Can't you just pop my neck?" When I persisted he acquiesced and a three-view cervical series was taken. The first image depicts the lateral film from the series. A metal strap or bracing devise used for joint fusions and fracture repair can be seen attached to the patient's mandible, with screws indicating a previously broken jaw. This injury and the resulting surgery were not reported by the patient. Surgeries were denied on the paperwork completed by the patient in the reception room and during our interview.
The film was shown to the patient as I made the statement, "Sometimes things heal so well we forget they happened. Tell me about this." Reluctantly, the patient explained he had received the jaw injury during a fight two years earlier while an inmate in the state prison system. He then confessed that the current complaint was a result of a bar fight over the weekend.
Trauma of this nature would and did lead to cervical problems. The additional information had an influence on my diagnosis and recommended plan of care. The patient began a course of care, but dropped out after he received moderate relief and regained most of his cervical range of motion.
Case #2: "Shoot, I Forgot..."
This case involved a 65-year-old female with neck pain. She reported hitting her forehead on a beam in her attic while searching for Christmas decorations two weeks earlier. She said she'd felt a sharp pain in her neck when she hit her head. The pain had persisted since the incident.
Her physical exam was unremarkable. Orthopedic and neurological tests were negative. There were mild decreases in cervical range of motion, but it was difficult to determine if they were related to the current complaint or were normal considering the patient's age. Fixations and tenderness were noted at the C5-C6 level; the patient indicated that this area of tenderness was the site of her pain.
A three-view cervical series was obtained. A portion of the lateral view has been enlarged and appears as the second image. An irregularly shaped object with a metallic density appears in the mastoid area of the cranium. Two lucent circular areas are seen next to the metallic object.
It appeared that the patient had metal in her head and that efforts to remove it had been made by drilling holes in her skull. A quick recheck of the patient's surgical history showed she had previously undergone a hysterectomy and removal of her gallbladder. I returned to the patient and said, "Mrs. Doe, you listed two surgeries, a hysterectomy and a gallbladder removal. However, after looking at your X-rays, it appears that you have had some form of brain surgery?"
Her response was, "Oh honey, I forgot to tell you, I got shot in the head in 1972." This had no bearing on the current condition, but it is difficult to believe this could happen to a person and they would not think to mention it during a health history. If I had survived being shot in the head, it would be the first thing I mentioned in a health history, even if it were just as a matter of pride. The patient showed absolutely no signs of mental or emotional deficit.
Case #3: Surgical Amnesia
My third patient was a 72-year-old male with rheumatoid arthritis. His chief complaint was aches and pains everywhere. In addition to his rheumatoid condition, he had suffered a previous heart attack and his gallbladder had been removed. Otherwise his history was unremarkable and he seemed to be in pretty good health.
His physical exam also was unremarkable. Other than normal signs of aging and findings typical for rheumatoid patients, there were no findings. Following the exam, cervical, thoracic and lumbopelvic X-rays were obtained. When the films were processed and placed on a view box, several wires were seen wrapped around the patient's sternum. It was obvious the patient had experienced open-heart surgery.
When I showed the film to the patient and asked about the surgery, he told me, "I didn't think that would have any effect on me seeing a chiropractor." He followed this with the question, "Hey Doc, did that big aneurysm they say I have in my stomach show up on those X-rays?" It hadn't.
Case #4: None of Your Business
My fourth and final patient was a 73-year-old male with lower back and leg pain. Since prostate problems commonly produce these symptoms in gentlemen his age, I was careful in reviewing the initial paperwork where questions regarding prostate and urinary problems appeared. All questions along these lines were negative.
The patient's physical examination produced only mild findings. X-rays showed significant lumbopelvic degeneration. A diagnosis of lower back pain with sciatica related to the patient's degenerating spine was assigned and care began. Two weeks of care produced no improvement.
At the beginning of the third week, I received a phone call at 7:00 a.m. from the patient's wife. She was frantic. "My husband hasn't urinated for two days," she told me. I said, "That sounds like his prostate; take him to the hospital right away." Before she hung up she said, "I knew it, he has trouble with that thing all the time."
I was upset. How could I have missed that? I was sure he'd told me he never had prostate problems. Was I mistaken? When I arrived at the office that morning, I pulled his file and just as I had remembered, he had checked "no" under every question that would indicate the existence or possibility of prostate problems.
Several days later my patient returned to the office after prostate surgery. When I asked him why he had marked everything no and had not told me about his prostate problems, he simply said, "You're a back and bone doctor. You don't need to know about that."
Stories like these are probably common for practitioners who have spent a long time in this profession. They are battle scars. The ones detailed here all had relatively good outcomes, but nonetheless, they are a reason for concern. What patients forget or won't tell you can hurt them and you. The lack of key information can result in misdiagnosis, inappropriate treatment and possible patient injury. This, in turn, hurts the doctor and their practice.
The moral of the stories is to always ask the extra question. Questioning and history-taking do not end when the forms are completed and the examination begins. They continue through the examination, X-rays and ultimately throughout care.
Author's note: I refer the reader to several of my previous articles for additional information. The recommended articles are referenced below.
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