One Day at a Time
Health Notes -One Day at a Time
“I think it’s just a virus, a stomach virus, Really. My wife had the same thing.” The wizened man looked at me, just above my eyes. “I’ve been married 67 years.”
The 87 year old man smile slightly. He was actually frightened, but could not say so. Also a bit embarrassed because I’m a female doctor and not his regular doctor, and his reason for coming today was rectal bleeding.
“I married her right out of high school, “ he added.
I asked him about the bleeding, when it started, if it was painful. After a meal out, he said. His Sarah had a stomach ache too, but not the bleeding. More questions, more answers. No fever, no vomiting, no belly pain, no respiratory symptoms, chest pain or urinary symptoms.
The list of diagnoses we doctors have been taught to formulate in our minds as soon as the symptoms mount up, the “differential diagnosis,’ or just “the differential” spat out possibilities: food poisoning, gastroenteritis, diverticulosis and a bleed, diverticulitis, inflammatory bowel disease, trauma (unlikely), cancer (low on the list), other tumors, genetic malformations, torsion, rare metabolic diseases, and so forth….
I quietly informed him we would need to do a full exam, including the bleeding area. Such an exam is clinically appropriate and of great clinical importance, but I was also keenly aware of wanting to preserve his dignity. While to the doctor viewing any part of the anatomy poses no issues, to frightened patients, trust, belief and hope intermingle with fear, modesty and propriety. Some patients refuse to be examined, usually out of misunderstanding—a common group is teenagers whose bodies are changing rapidly and who are often fearful and adamant about avoiding physical exposure. Examination is important for health. And an exam, a full exam, could not and should not be avoided today.
“She gets angry if I look at another woman. She hits me.” He flashed a brief grin. This frail man was so much like my own father, also 87, also fiercely married to a woman for more than six decades and also the primary caregiver to his failing, fragile spouse.
With my assistant at my elbow we carefully helped him onto the exam table. Gentle reassurance given, drapes, discreet exposure of the concerning areas only as needed by the examiner revealed blood, significant blood. No pain, no tenderness. On the differential cancer rose higher up the list.
Stat labs were not stat that day, It happens. I returned to the room after he had dressed. I discussed the possible diagnoses, emphasizing that we didn’t know what the problem was, playing up the common issues, such as diverticulitis and a local bleed,easily treatable, and downplaying the frightening specter of cancer. While cancer was on our minds, there is no reason to perseverate: common problems are common. We strive to rule out the bad stuff, and remind ourselves that the common, treatable problem, is more likely.
His labs came in later that night. His blood count was consistent with infection. A few phone calls, an admission to hospital later confirmed the treatable condition of diverticulitis, a gut infection He was treated, improved and released two days later.
I am grateful he presented to us, despite his fears, and especially when he would not see his own doctor that day. While common things are common, they are not commonly treatable at home and medical intervention is required. And sometimes the common thing is not what is presenting that day.
Clearly this patient had a sense that things were out of the ordinary. The next step is the bravery to act on that hunch. When patients follow through I am always grateful.