On listening to the patient

Osler, often referred to as the Father of Modern Medicine famously said: "If you listen carefully to the patient, they will tell you the diagnosis.” He emphasized both the value of a careful history in medical diagnosis and the value of learning from one’s patients. Ask any practicing clinician and they will have anecdotes that illustrate how right he was. One stands out for me.

She came to the ED one evening, afraid to go to bed ‘because of the worms in my nose.’ She was not the kind of patient popular in the ED. A native of Cameroon, she had been in the US for only several months. Her hygiene was poor and her English was worse. This was before the era of mandated translators, and it is unlikely one would have been available for her Niger-Congo dialect. She had no insurance. And she was visibly agitated (medical speak for upset).

The charge nurse in the ED decided she needed to be evaluated by psychiatry. This meant that a third year medical student (me) was assigned to do a brief medical history and exam, and then present the case (on the phone) the the psychiatry resident. Taking a history was a challenge. Through an accompanying family member, I learned that she periodically was awakened from sleep by demons in the form of worms that were trying to choke her by crawling into her nose.  She was taking some native remedies I could neither spell nor pronounce for abdominal pain and cough. She had never had surgery but had borne 8 children, three of whom were still alive. Her examination was unrevealing. 

I called and presented this to the psychiatry resident. His assessment was that she was probably paranoid and delusional and should be admitted to the psych floor for medication, with a plan for a medical consult in the morning with regard to her abdominal and pulmonary complaints. I offered to do lab, an EKG and a chest x-ray in the ED, but he declined, saying it would mean she would arrive on the ward ‘after shift change’ when staffing was lower.

Off she went, admitted with a diagnosis of paranoia with delusions, while I continued seeing patients in the ED.

About four hours later, the charge nurse asked me if I wanted to sew up a scalp laceration on a nurse. It wasn’t often a third year student had the chance to do procedures like this, but the nurse had seen me sew up a few others with supervision, this was a small one in an area (covered by hair) where a small scar would not be an issue, the patient had been evaluated by the surgical intern who had been about to start the repair when he had been interrupted to put in a central line, and the nurse with the laceration needed to get back to work as soon as possible.

I entered the room and she was already lying down, all draped and prepped. It was, indeed, a small and simple laceration and only required two stitches to close the wound and stop the bleeding. To pass the time - and disguise my anxiety - I asked what had happened. She had been making bed-check-rounds on the psych floor where she worked and had looked in on the new admit from the ED, the lady with the delusions. When she directed her penlight beam at the sleeping woman’s face she had been greeted by the sight of 4 inches of worm coming out of her nose and a second worm coming out of her mouth. She had promptly fainted, hitting her head on the edge of the chair on the way down. 

After finishing the laceration and discussing wound care, I called the psych floor to ask about the patient from Cameroon. She was no longer there, having been transferred as fast as the psych staff and resident could arranged, and was now on a medical floor for evaluation of a pulmonary roundworm infection. 


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