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The Patient With Multiple Problems
Responding to the home of an 80-year-old man, you are led into the bedroom by his wife, where you find your patient in bed, propped up on several pillows with his knees drawn up. He is using a nasal cannula attached to an oxygen concentrator, and you note an ashtray on the nightstand by his bed.
He speaks to you in short sentences and apologizes for his shortness of breath. You make a mental note that his respirations are noisy. He says he has severe emphysema, and adds that he’d really rather not go to the hospital. “I’m not going to the damned hospital,” he says firmly, between labored breaths. His wife says, “Now, Charles, don’t be that way. Tell them what’s going on.”
Charles says he thinks he may be constipated because of sharp pains he has experienced in his lower left abdomen since yesterday. He describes it as a constant burning pain, rated as a 5 on a 1-10 pain scale. He appears to be in moderate distress.
As our population ages, we see more patients with chronic conditions, sometimes more than one. It can be difficult to sort out exactly what is going on with a patient, and whether his current problem is chronic, acute or a combination of both.
While we are always told that as medics we are not to diagnose, everybody in emergency medicine knows that we do a certain degree of diagnosis. If we did not, we wouldn't be able to treat our patients. Whether we call it “field diagnosis,” “working diagnosis” or “presumptive diagnosis,” what we do when we see patients1 is try to figure out what’s wrong and what we can do for them until we get them to the hospital.
From the patient’s point of view, there are a few fundamental questions: (1) What is happening to me and why? (2) What does this mean for my future? (3) What can be done about it, and how will that change my future?1
Our job is to listen to the patient, examine, interpret, explain and treat.2
When we have a patient with multiple problems, this process is essential, for if we fail, we will miss the real cause(s) of the patient’s current problems.
Patient History
There are many formats for history-taking. There are SAMPLE histories, OPQRSTU questions, and a plethora of other mnemonics that are memory aids for formulating questions to ask the patient. But ultimately it all boils down to asking questions that will tell us who, what, when, where, how and why.3
Who is this patient? What can we learn from observation? What questions should we ask? We surely must find out about his past medical history. In some cases, his family history will become important. For example, is there a history of heart disease in the family? What are the patient’s habits? Are they healthy or unhealthy? In this case, we can see at a glance that Charles has one unhealthy habit: smoking.
What is happening right now? Letting the patient talk is your best method for finding out exactly what is going on. Being a good listener is hard for some medics, because we are action-oriented, aware of time, and want to get the basics over with as soon as possible. However, patients with chronic conditions may have a very good idea what is wrong, and they will tell you if you let them. Keep in mind that patients will sometimes omit information they think is irrelevant, and elderly patients may have forgotten something like a fall that happened a few days ago. No symptom is irrelevant. Often, they will omit medical conditions if the symptoms of those conditions are well-controlled by medications. Allow your patients to speak freely. Don’t interrupt to ask for details until they've been allowed to tell you what they think is happening.4
When did this start? Timing is important. How rapidly has the problem progressed? This can be important in many situations, among them cardiac problems and infectious processes.
Where is this happening? All disease processes involve some body system or process. The questions we need to know are: Is the problem localized or diffuse? Is there a definable pattern in the signs and symptoms?5
How did this problem develop? People become ill in a number of different ways, but there is always a reason why something is happening. To find this out, we become medical detectives. What went wrong? How did it go wrong?
Why is this happening? Why and how often merge.
Using this approach, you begin to question Charles. You learn that he was an athlete in his younger years and played college football. He went to work in a brokerage firm, took up smoking, and at one time smoked five packs a day. Now he says he only smokes “when my wife is out of the house.” He says he began having breathing problems 10 years ago and was diagnosed with emphysema. He had a heart attack seven years before and had four coronary artery bypass grafts at that time. Since then, he has limited his physical activity because he “just doesn’t have the energy to do much these days.” He has gained a lot of weight and says he weighs about 275 pounds.
When you ask him to explain exactly what is happening to him now, he says, “Well, I’m just falling apart, I guess.” You ask how, and he says that he can’t breathe well, particularly at night when he’s trying to sleep. He has to put several pillows under his shoulders to get them up so he can breathe. His doctor has prescribed nitroglycerin spray and told him he should use it when he wakes up unable to breathe.
Your partner has already placed the electrodes for a 12-lead ECG and applied the pulse oximeter to the patient's index finger. His oxygen saturation is 84%. You run the ECG, and it reveals prominent Q waves in leads II and III, but no ST elevations.
The Focused Medical Assessment
We normally do a focused assessment based upon the patient’s chief complaint, but, in this case, the chief complaint doesn’t seem to be his main problem. So we'll have to do a much more thorough assessment to try to figure out exactly what is happening. In this case, we should start at the head and work down. The physical exam will be summarized in standard medical fashion.
Visual impression of patient: An obese male lying in bed with legs drawn up and wearing a nasal cannula. Appears to be his stated age. Engages the medic appropriately and answers questions appropriately. States his name, location, day and month, and why he called EMS.
Vital signs: Pulse is 110 beats per minute, BP 168/104, RR 30 and labored, pulse oximetry is 84% on room air and tympanic temperature is 100.2ºF.
Head, eyes, ears, nose, throat (HEENT): Head is normocephalic. There are no signs of trauma or deformities. Pupils are equal and respond briskly to light and by accommodation. Tongue is pink and somewhat furrowed; buccal membranes are pink; teeth are absent and dentures are in place. There is an odor of bad breath.
Neck is supple and non-tender, with no sign of trauma or deformity. Jugular veins are distended, and the patient is sitting up in bed. Trachea is midline, and there are no palpable lymph nodes.
Chest: There is a scar running from the top of the sternum to the xiphoid, consistent with the reported history of CABG. There are no other surgical scars. Barrel chest is noted, with increased anterior/posterior diameter consistent with emphysema. Auscultation reveals rales in the bases of the lungs with rhonchi in the bronchi. Heart sounds S1, S2 and S3 are heard. There is equal chest rise and fall, and percussion reveals no tympany or abnormal dull sounds.
Abdomen and pelvis: Inspection reveals no surgical scars and no distention. Brief auscultation reveals bowel sounds. Palpation reveals no masses or pulsation. Palpation of the LLQ elicits pain. Palpation of the other quadrants reveals no rebound tenderness (Blumberg’s sign). Percussion reveals normal sounds over solid organs.
Lower and upper extremities: No signs of trauma, tenderness or deformity.
Back: No signs of trauma. No tenderness.
Patient Evaluation
Now it is time to evaluate the findings and try to decide what is happening to this patient.
While the patient’s chief complaint when calling EMS was abdominal pain, it has quickly been determined that he has some other immediate problems.
Fever and the location and quality of his abdominal pain suggest an infection, possibly diverticulitis. Approximately two-thirds of people over age 80 in the United States have diverticular disease. Diverticula are small pouches in the wall of the digestive tract, usually the descending colon. Diverticulitis is inflammation of diverticula.6
However, this is not the main concern for this patient. He has obvious pulmonary edema.
The EMS crew explains to Charles that he needs to be examined in the hospital, and that his infection could get worse if not treated. They also explain that they can treat his shortness of breath. Charles agrees to allow them to treat and transport him. They start him on CPAP and oxygen and give one dose of nitroglycerin spray. His breathing immediately improves and the transport is uneventful.
In the hospital, he is admitted and started on antibiotics. The cardiologist is called to evaluate his heart condition. After two days he is discharged home, much improved.
Conclusion
It is common to find elderly patients with multiple conditions, some chronic, some acute. Charles was suffering from both, but they were unrelated. It was essential that the medic did not develop tunnel vision. In this case, a thorough history and physical exam paid off.
References
1. Cohen JJ. Remembering the real questions. Ann Intern Med 128:563–566, 1998; Kravitz RL, Callahan EJ. Patient’s perceptions of omitted examinations and tests: A qualitative analysis. J Gen Intern Med 15:38–45, 2000; cited in DeGowin’s Diagnostic Examination, 9th ed., p. 2.
2. DeGowin’s Diagnostic Examination, 9th ed., p. 3
3. Op cit.
4. Op cit, at p. 4.
5. Op cit.
6. Cunha JP. Diverticulosis and Diverticulitis, eMedicine Health, https://www.emedicinehealth.com/diverticulosis_and_diverticulitis/article_em.htm.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the Louisiana Association of Nationally Registered EMTs. He is a frequent EMS conference speaker and the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.
