When I was training, my colleagues and I were told by the clinical giants of the Greatest Generation that “the history” should account for more than 95% of the evaluation of chest pain. That concept still applies in my book – even in the biomarker era – and not just for chest pain, but for understanding the nature of a heart failure exacerbation.
Wikimedia Commons/David R.Tribble/CC License
Drilling down has its diagnostic rewards.
Recently, a patient with known systolic heart failure presented with worsening lower extremity edema and weight gain. When I inquired about diet, the patient denied excess salt ingestion, stating that she never used a salt shaker or ate frozen dinners. I asked the patient if she ate out at restaurants and received a negative answer.
At this juncture, I could have moved on. After all, there were no more RVUs to be had with this line of questioning. But here is where “drilling down” helps. I asked: “What do you eat for dinner on a typical day?” The response: burgers and fries from the local fast food joint. It turns out that the patient uses the drive-thru at White Castle 5 days a week and then eats at home. So it’s not “eating out.” A bit of concrete thinking was used, perhaps, but that’s fine.
It proves the point that “the history” remains one of the most powerful tools in the clinical medicine.
Fracking, cardiology style. There are no environmental concerns, only greater insight into our patients.