Always Listen to Your Patients

This is not an advice column for anyone but rather a clinical reminder for myself to always be thorough and listen well. I don't want to jeopardize anyone's identity here so won't be going into specific patient stories or details. I cannot emphasize enough that the answer usually lies within patients' stories. Patients' stories guide us on what to look out for during physical exam and hence, lead us to appropriate diagnosis (or -ses) and treatment. It takes practice to become a sharp/shrewd listener, and it can be time-consuming when it comes to long and circumlocutory stories, but most of the time, it pays off.

But before first, always check for red flags and need for immediate intervention. Like the dreaded substernal chest pain. Or crescendo headache that reaches maximal intensity within seconds. If not, safe to enter next phase - story time.

When a patient with a GU complaint says "I feel like something heavy is dropping" or "something has dropped" while voiding - it's worthwhile to perform an external genitalia exam. Might not find something unusual but sometimes you do uncover the cause. In my experience, I've discovered bladder prolapse in a multip and a lodged kidney stone at the urethra exit in another patient (though very rare, from what seasoned clinicians tell me) that way.

Also, even when the chief complaint sounds like an uncomplicated UTI in a female patient, check for possibility of vaginitis by doing a ROS (unusual vaginal discharge, odor, pruritis...etc.). This is especially important in someone who happens to be an unreliable historian. And just check anyways to make sure you are not missing out on a blatant screaming-angry-red candidal vulvovaginitis.

When a patient with a history of cancer complains of "I feel like there's something in my neck" or "a lump/bump/mass", take the time to do a thorough check for any cervical, supraclavicular, or infraclavicular lymphadenopathy. Could probably benefit from performing a generalized lymph exam too. If you do it too quickly, you might not pick up tiny nodules.

When a perimenopausal patient complains of missing her menses for an x amount of time, check for possibilities of pregnancy anyways. Just to rule it out and kick it off the differential list. Ask for breast tenderness and associated s/sx of pregnancy. Even in someone with a history of tubal ligation or Essure. Then do a urine dipstick for pregnancy.

Ultimately, patients are the experts of their body. They know what's up or when something kooky is going on. They know what works for them. Plus, not everyone shows up to clinic at the drop of a dime. They usually wait and try different remedies until it is too bothersome for them to handle. So by the time they come to you, doing a thorough exam is warranted. Trust them. Unless there is an absolutely good reason not to (e.g., obvious & active inebriation, intoxication, thought disorder, etc.).

Don't forget - Talk yourself out of other urgent possibilities for differentials & prove that there is nothing else dire going on before deciding on treatment. And NEVER assume any information not offered or not provided by your patient.

And yes. Do all of this in 15 minutes if you are a true master. Though your patient might not like you. So most importantly, just listen carefully.