Observation

I am to do a case presentation in two weeks. In choosing my case I was reminded of another patient – somewhat like my sentinel case because the entire time I was assessing the patient I am going to present, I was thinking about the other patient.

 

My sentinel was a middle aged woman who did not know why she had been brought to the hospital. She had no complaints and her examination was unremarkable except that she was disengaged and avolitional. She was not psychotic or depressed and this affect was entirely new.

 

She recovered whilst in the ED before her admission to the medical ward and we spoke again before her admission. She said to me that she knew earlier that something was wrong, but that she could not be bothered. I would tell you my diagnosis, but that would be a spoiler for my next presentation and it is not my diagnosis that is the point of this post; rather that medicine is an education in observation.

 

There is an old joke in medicine about the student who failed an OSCE for a simple lack: he did not ask the patient his name. The patient had no somatic complaints and his physical examination revealed nothing abnormal. The student’s diagnosis was “Normal” and the patient’s actual diagnosis was “Psychosis”: he believed himself to be Napoleon.

 

An acute observation can tell by a woman’s walk whether she is ovulating or menstruating; by a child’s resting expression how well he slept the night before; and by an old man’s signature how good a day he is having. We are all unconscious broadcasters of our fundamental states.