EBSALUTA’S MAR [15-09]: A Hard Lesson on Patient Management

Medical Anecdotal Report
Indexing Title: EBSALUTA’S MAR [15-09]
MAR Title: A Hard Lesson on Patient Management
Date of Medical Observation: September 2015
Tag: A reminder on the importance of a good history and physical examination
Category: Professional/ Ethical, Reinforcement


It was back in February when I first met the patient. He is a 67 year-old-male with previous complaint of blood-streaked stools. I took the patient’s history back then and aside from his chief complaint has no other symptoms of abdominal pain, no vomiting, no melena, no noticeable decrease in caliber of his stools, nor weight loss. When I examined the patient, he had flat, soft abdomen, without any palpable masses. I performed the digital rectal examination on the patient, and noted that he had no hemorrhoids, full rectal vault, with no blood per examining finger, and only an anal fissure was observed. I sent home the patient with a prescription for suppository and advised him to increase his intake of fiber.

I had not heard of his follow up, and it was already May, when he sought consult again. This time he complained of recurrence of blood in his stools with abdominal pain. On examination, the patient had flat, soft abdomen but with tenderness at the left periumbilical area. I remember to have palpated no masses then but I have already a suspicion that this was not a simple case of abdominal pain. I sought consult with my seniors and they recommended to have whole abdominal computerized tomography (CT) scan and colonoscopy for the patient. The patient and his sister then told me before they left that though they are financially poor, they would do their best to have the requested laboratory examinations done. I then told them that I would do my part in making sure that the patient get through his condition.

It would again be another few weeks, before the patient returned with the CT Scan result. The result showed a mass in the descending colon but could not differentiate between a diverticulitis (pouches in the colon become inflamed) versus a colonic mass with perforation. He was then advised to still undergo colonoscopy. I guided them through the process of cardiopulmonary clearance and reminded them to return for the scheduled date for his colonoscopy. The patient, however, was a no show during the first schedule. The patient would still take a while before he returned to the hospital for his colonoscopy. Unfortunately when it was finished, his colonoscopy showed an obstructing mass on the descending colon. The patient was then immediately scheduled for resection of the colonic mass on the following operative day.


Category: (Physical, Professional/ Ethical, Psychosocial) (Discovery, Stimulus, Reinforcement)

During medical school the importance of a good and complete history and physical examination is always drilled to us to master. No laboratory examination could replace it and it would actually lead us to a focused management on the patient. For my part, I try my best to gather a complete history and physical examination to every patient that I encounter. It is just unfortunate that I have missed the diagnosis in the patient during his first consult. I already have an inkling then that it is not just a mere case of benign anal disease but I ignored my better judgement and went with what is the obvious. And so when I met him again, during his second consult I knew then that I was given another chance to correct my shortcoming. It was a bitter pill for me to swallow, as I reviewed the chart; tried to remember our initial conversation and the physical examination afterwards. But after a while, I came to terms to the fact that the patient’s symptom recurred and now it paints another picture of his condition.

Thankfully, although the patient had already declared himself on the onset to fall in the lower economic stratum, I knew with the way he looked me in the eye and his polite but firm responses that he wanted to get better still. It was a tedious process but we were able to operate on the patient. And as part of my commitment that he would not receive a half-baked management, I already explained to him and his sister that he would still need to undergo radiotherapy for his condition when he gets better. I told them that this should be done a month after the operation and not a whole year after. They told me that with their minimal resources they would do their best to go forth with the radiotherapy.

ROJoson’s Notes (16jan6):

  1. There is no such thing as 100% certainty on a clinical diagnosis despite a complete history and physical examination.  There is always a secondary diagnosis or differential diagnosis.  All physicians should keep this in mind and act accordingly.
  2. Doing a paraclinical diagnostic procedure is dependent on the degree of certainty of the physician on the primary and secondary diagnoses.  If the physician is quite certain of the primary clinical diagnosis, no paraclinical diagnostic procedure is needed and definitive treatment administered.  Nevertheless, the patient should always be advised follow-up to monitor not only the outcome of treatment, but also the correctness of the diagnosis.  Remember there is no such thing as 100% certainty in the initial clinical diagnosis.  Only time will tell whether the clinical diagnosis is correct or not.
  3. If the above philosophy, principles, approach and attitude are understood and adopted, then the physician should not be saying: “It is just unfortunate that I have missed the diagnosis in the patient during his first consult.”  He /she is entitled to change his / her diagnosis on follow-up (as long as such an advice is given) when there are new symptoms and signs appearing and there is a reevaluation of the diagnosis.
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