8:14
Today is Sunday, and you are on duty. The drizzling rain is not an excuse for being late; staying up too late is.
You hurriedly rush to the changing room. Just as you finish changing, the nurse pulls you to see an elderly lady.
Bed 5—a figure who has appeared in your sight many times before, fleeting past the office doorway—a short, chubby elderly lady with a brace around her waist, slowly maneuvering a wheelchair. Only after reviewing her medical records now do you realize she is an elderly lady undergoing conservative treatment for a lumbar vertebra fracture.
There are many patients in the ward, and you haven’t been able to remember every one of them—that’s how you comfort yourself. The nurse urges you again, and there isn’t time to carefully finish reading. You skim through the diagnosis and come to the patient’s bedside to ask the elderly lady where she feels unwell.
She crosses her arms, frowns thoughtfully, responding from time to time, like a stupid Siri on an Apple phone:
…Hmm
…Oh, oh
…I see
The elderly lady says a lot, but you’re unclear about where the issue exactly lies. You only catch a few seemingly critical pieces of information: pain in the right upper abdomen radiating to the right armpit and left upper abdomen, stabbing pain, unbearable, just started recently.
You try to construct a clear reasoning network in your mind, but in the end, you only grasp a few scattered bits of knowledge. You think of cholecystitis, then myocardial infarction, and then you can’t think of anything else.
While your brain slowly processes, your hands and feet are busily working—measuring blood pressure: 133/78 mmHg, normal for elderly people; checking the ECG—it looks fine, heart rate okay, rhythm okay, no ST elevation, and you don’t understand the rest. Fortunately, you can compare with the ECG taken a few days ago upon admission—the results are almost the same, which reassures you. Asking the elderly lady again, she denies chest tightness or chest pain—only right upper abdominal pain.
Now you feel the patient’s vital signs are stable, so it’s probably not a serious matter. The tense knot loosens, and some knowledge points you haven’t reviewed for a long time resurface in your brain. Oh right, cholecystitis—check Murphy’s sign. You press the correct spot, tenderness and rebound tenderness are negative; pressing the entire abdomen, no positive signs.
Not cholecystitis, seemingly not a myocardial infarction either, and you can’t think of anything else.
You return to the office and look more carefully at the medical history in the admission record—no mention of abdominal pain. You fall silent, trying once again to squeeze some differential diagnosis knowledge from your not-so-large brain.
The rain outside keeps dripping, the clock in the office keeps ticking. You don’t know how long it’s been, but certainly not long. You give up thinking and decide…
to be continued