Thursday, 10 June 2010

Don't listen to the patient!

With apologies to Sir William Osler. For it was he, who is an icon of medical education and a former Regius professor of medicine at Oxford, who coined the aphorism, 'listen to the patient, they are telling you the diagnosis'.

The aphorism is indeed incredibly useful and a reminder of just how important history taking is in the practice of medicine. With today's over reliance on high tech scanning and other tests, it is a reminder that the fundamental skill of carefully and actively listening to the patient tell their story, remains central to diagnosis.

But...patients can lead you astray. I saw this 30 year old chap yesterday. He told me that he had been doing some gardening the previous bank holiday weekend and had strained his upper back. I confess I wasn't hugely concerned and had a very cursory look at his mid-back and palpated the paraspinal muscles to elicit some tenderness. As I sat down to suggest anti-inflammatories, he pointed out just a couple of spots over his antero-lateral chest. All too slowly the penny dropped and I had a more thorough look at his back-and there they were, the tell tale clusters of papules of herpes zoster.

I couldn't believe that I had not noticed them during my first look at his upper back. But I was looking and not seeing. Already accepting his account of the explanation of his pain, and sadly not using my own judgement, I was composing a quick response whlst 'looking' and hoping to catch up in a busy clinic. Quite simply he lead me astray!

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