Indexing Title:  HABalucating 06-04

MAR Title: Conversant or Non-Conversant

Date of Medical Observation: May 2006

Narration:               

                “Which is more difficult, conversant or non-conversant patient?”  This question was asked to me by my senior right after seeing two totally different patients at the ER that have both given us a hard time.

                It was a quiet Saturday duty when a 30-year old, female patient was brought to our ER.  The patient allegedly was driving a sedan when she was hit on her passenger side by a moving van.  She allegedly bumped her head into something sustaining a lacerated wound on her right occipital area and apparently had loss of consciousness.  She claimed that after the mishap, she had no recollection of the event and the next thing she remembered after the accident was she was in a taxi on the way to the hospital.

                At the ER, she was conscious, coherent, oriented to 3 spheres and has no signs of any neurologic deficit.  We asked one of her companions to sign her up at the information and was assessed by one of the medical clerks-on-duty.

                I approached the patient and started taking brief history and P.E.  During that time, the patient was busy talking to somebody over her cellphone so I waited for several minutes to finish her conversation before I could do my interview.  After her phone conversation, she started talking to her companions about what happened in the accident, her damaged car, things she left in her car, her complains of headache and dizziness, among others.

                Most of the details in her history I gathered were not directly addressed to me but what I heard during her story-telling session.  I then made a quick P.E. and assessment of her neurologic status which seem to be essentially normal except for a 3 cm scalp laceration on her R occipital area which is not bleeding or gaped.  I instructed the medical intern to clean and suture the wound, provide tetanus prophylaxis and get the skull X-ray of the patient.  I noticed that she was again talking over her cellphone while simultaneously relating her story to her companions.  She seems to be enjoying the attention she gets.

                As the intern was about tostart suturing, one the head of our administrative staff approached me and asked me about thye status of the patient.  I told him that she is alright and just had a minor injury.  He then told me that the patient is a lawyer and works for somebody important in the Department of Immigration.  Apparently, a certain important person called up his office notifying him about the patient.  According to him, the patient was not satisfied with how she was accommodated and no doctor had seen her yet.  I politely disagreed to the allegations which I think he understood.  I then sutured the wound myself.  After suturing, she had skull X-ray which as predicted, revealed normal result.

                I advised the patient regarding head injury precaution and told her that she is OK for discharge, but she stayed at the ER making more phone calls and telling her version of the story.  She even made me talk to her private doctor t5o explain her condition.  After a while, she then decided to leave the ER to file a complaint to the driver.  Before leaving the ER, she  asked a more irritating question: “Magkano babayaran ko?”

                During that time, I also received a referral from Pedia-ER regarding a a 10-year old male patient with a Global Developmental Delay with 1-week history of  fever and abdominal pain.  Their PWI is UTI r/o acute appendicitis. 

                When we first saw the patient, he was febrile and irritable.  It was difficult for us to assess his abdominal status because he would cry everytime we put our finger over his abdomen.  We advised the Pedia intern to call us up again when the patient is sleeping so we could properly do our P.E.

                After several hours, the Pedia intern called us up.  As we are about to start our P.E. of the abdomen, the patient again started crying.  We tried several times but the patient is uncooperative and irritable.  We could even illicit thye same response by putting our finger over his forehead.  We requested UTZ of the RLQ area and advised the Pedia service to admit the patient so we can do our follow-up at the ward.  The UTZ revealed normal result and the fever and the abdominal pain was relieved on his 2^nd HD. 

Insights (Physical, Psychosocial, Ethical)   (Discovery, Stimulus, Reinforcement) 

                Both patients presented as difficult patients, one is a diagnostic dilemma while the other is a test of my ability to build rapport to my patient.

                There are several occasions that I would encounter patients that would really test my patience.  Because I am a doctor and is assumed to know better of the patient’s condition, I should always  try to give my patients the best care I could.. whether conversant or non-conversant.