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