The importance of reading patient charts

A patient came in today complaining of stomach pain and alternating constipation and diarrhea over the last 1-2 months. She wanted a referral for a colonoscopy.

She said that she has had stomach pains since childhood (likely related to abuse that she suffered) but that her stomach got much worse over the past year to the point that she hasn't been able to eat without feeling nauseous and sometimes throwing up. She denied blood in her stool, denied black stools, but said that here stools were "greasy." Moreover, she said that she lost about 50 pounds in the last year without trying to lose weight, going from a waist size 44 to a 34. She denied fevers and chills but said that she sometimes woke up in the middle of the night with the bed drenched in sweat.

She has a 100 pack-year smoking history under her belt as well as a substantial history of drug abuse of many drugs. Her family history is significant for her mother who died of colorectal cancer when she was 60 years old.

I was obviously very concerned about possible colorectal cancer with this history. As I presented the case to my attending, though, she didn't seem to share my concerns. Why not?

My attending had provided me with limited background to this patient's case but threw me in the room without giving me time to review the patient's chart. After I had finished the interview and exam, I didn't have any time to look into the chart before my attending wanted to hear about our patient.

My patient did in fact unintentionally lose 50 pounds in less than a year, but that was two years ago; her weight has been stable since then at a healthy BMI of 24.0. When her weight was in a free-fall, my attending was justifiably very concerned about possible cancer.

My attending tried at the time to convince our patient to get a colonoscopy, but the patient refused. Now she came back a year-and-a-half later because her symptoms got worse, and she was requesting the colonoscopy.

All of this underscores the importance of reviewing the patient's chart and corroborating the patient's story with objective evidence or documentation whenever possible. This patient was unable to provide critical details of her illness that shifted concern away from the possibility of colorectal cancer.

It would be very easy for me to jump to the conclusion: Don't trust patients. It's more complicated than that, though. I think that a large portion of patients are unfortunately poor historians, but it's also true that doctors often rely on patients' subjective experiences in deciding on a course of treatment. My job, then, is to make a judgment call of how much I can rely on the unsubstantiated "testimony" of my patients and to seek objective corroborating evidence whenever possible. That's what a physical exam is for, and that's what chart review is for.

Thankfully, my attending acknowledged that she hadn't given me time to review the chart and that I couldn't have known these pertinent facts that conflicted with the patient's story.