Estoy preocupada.

The 'History and Physical' is the legally accepted documentation at the start of any Physician-Patient relationship.

I remember taking hours to complete a single H&P in medical school. When we were observed for a grade at the end of each semester we had 1 hour to complete our interview and physical exam and then an hour to write up our report. Now granted, I did every aspect of a physical back then. Can't say I've actually taken out my ophthalmoscope since leaving Mexico. But really, when a patient has complaint of belly pain, the shape of their optic disk is of little consequence. Either way, it does not take me hours any more, not even close. The interview blazed through as I make my way down the checklist in my head, created from the practice of hundreds of H&P's.

Symptom?
Quality?
Where?
Duration?
Better?
Worse?
Associated symptoms?
Before?
Etc...

All-in-all it's pretty basic stuff, textbook. But then, once in a while I'm caught off guard.

Last week surgery was called to consult on a patient that had blood surrounding the spleen on CT scan, concern for rupture. The patient was young, not a child, but more like my age. Really no past medical history and had presented referred from a walk-in clinic with 3 days of left flank pain. They had suspected a kidney stone. However, the picture being painted on initial work-up in the ED was pointing more in the direction of leukemia. I went to see the patient. I talked with the ED doc first to get a general story before going in and was warned that even though the word leukemia was being plastered all over the patient's chart... it hadn't actually been mentioned to the patient yet. I acknowledged the forewarning... I wasn't about to be the one to use it first.

Besides, I had enough news to break to the patient as it was. "Hi, I'm from Surgery. We're here to be on board in case you start to exsanguinate into your belly, in which instance we would need to go in and take out your spleen.  But don't worry. You're fine. For now..."

Don't worry, I have a bit more finesse in real life. ;)

Either way, this patient seemed to sense what everyone wasn't telling him. Direct, single word answers whenever possible. Would make eye contact with me only when absolutely necessary. I quickly pieced together that the patient wasn't a typically happy individual at baseline and lacked a large support group. Pushing my way through to the end of my H&P checklist
"Do you smoke"
"Yes"
"How much?"
"about 10 a day"
"Do you drink?"
"Yes"
"Socially?"
"No" (eye contact was definitely avoided on that one)
"Do you use drugs?"
"Marijuana, but my spouse was gone last night so I did some coke."

And my heart sank. The road I saw laying out before this patient had suddenly gotten so much more difficult from a social and psychological stand-point.

I'll probably always wonder what happened. How that patient's story enfolded. The spleen aside...I'm not worried about the spleen. It was a beautiful spleen on CT scan. But in general, some stories stick more than others. This one wasn't even mine to worry about, but somehow I can't help it.

Much Love.