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From: werner@aecom.UUCP (Craig Werner)
Newsgroups: net.med
Subject: Answer to Medical Puzzle #5
Message-ID: <2202@aecom.UUCP>
Date: Sat, 18-Jan-86 01:44:17 EST
Article-I.D.: aecom.2202
Posted: Sat Jan 18 01:44:17 1986
Date-Received: Mon, 20-Jan-86 06:33:24 EST
Distribution: na
Organization: Albert Einstein Coll. of Med., NY
Lines: 42

> A young woman comes into the clinic with (obviously) a health complaint.
> 
> 	You ask what's wrong, and she says that her stomach hurts.
>  	You ask her to describe the pain further, and you find that it 
> is worse before she eats breakfast.
> 	You ask how long this has been going on, and she says it started to
> bother her a few weeks ago, but has gotten worse recently.
> 	You ask two more questions, the first of which is suggestive but
> non-specific, the second of which suggests the obvious diagnosis?
> 
> What is the informative question, and why do you ask? 

	This was an actual situation. The next question asked followed up
on the stomach (GI) symptoms, asking "Do you feel nauseous?" She didn't 
understand "nauseous."  Rephrasing, "Do you feel like you're going to throw
up?"  She answered, "Sometimes."  There was a slight pause as all the
differential diagnosis of GI disease goes through your head, competing to be
the next question, then all of a sudden, it dawns on you to forget about 
that and ask:
	"If I may ask, when was your last menstrual period?"

	She answered January, and this was in April.  The diagnosis: morning
sickness secondary to PREGNANCY. The interview continued for 10-15  minutes
with eventual referral to family planning.
	When I tell this to friends, especially female, they invariably say,
"How could she not have known she was pregnant?"  My theory is that the power
of denial cannot be underestimated.

	I was once told to remember three easy hints to catch the 
obvious: the most frequent cause of amennorhea is pregnancy, the most 
frequently found Suprapubic mass is a full bladder.

	One of my letters suggested an Ulcer. This would be a proper first
guess in a man of 40, not a young woman. Also, ulcers tend to hurt most a
few hours after each meal, not just in the morning.  Note, however, that if
she had NOT been pregnant, this would have to be considered.

-- 

				Craig Werner
				!philabs!aecom!werner
                 "What do you expect? Watermelons are out of season!"