Viewpoint: Getting 'schooled' by patients

March 25, 2011

In today's world of medical marvels, it's easy to forget the basics and be seduced away from the fundamentals of patient care.

I work in long-term care, which can be a hectic world, just as any other type of medicine can be today. We come to rely on technology and other people to help us do our jobs, especially when things get busy. We rely on computers and telecommunication systems to check on histories, and nurses and other ancillary staff to get information.

In today's world of medical marvels, electronic health records, and scans for everything, it's easy to forget the basics and be seduced away from the fundamentals of patient care. Fortunately, our patients have a way of setting us straight when we stray too far.

One weekend, my covering physician took a call from one of my nursing homes about a resident, Ms. Ferguson, who was having a garden variety urinary tract infection (UTI). He ordered an appropriate antibiotic Sunday evening.

That Monday morning, I received a call about Ms. Ferguson. The nurse told me that she noted the patient's face to be red and slightly swollen. She didn't have any more to tell me at that time but mentioned that she had antibiotics ordered for a UTI and also had received the flu shot the previous day. I asked her how many doses of antibiotics the patient had received so far. The nurse said that she didn't know but would get back to me. I told her I would swing by to see the patient later that day before her next scheduled dose of antibiotics.

The patient's history included some very serious illnesses, but she had recovered nicely. She had a history of some mild to moderate cognitive deficit, but she wasn't a very good historian. She was very pleasant and could make her needs known. I added her name for rounds that day and scribbled: possible allergic reaction?

When I arrived, the nurse I had spoken with earlier was with the patient. I looked at Ms. Ferguson's face while the nurse filled me in on the missing pieces of the history. Apparently, the antibiotics where ordered Sunday evening but hadn't arrived yet.

My initial working diagnosis of an allergic reaction to the antibiotics was toast. But apparently, the family, who was very involved, had taken her out on Sunday to a local pharmacy that was giving influenza shots. Could she have had a reaction to the vaccine?

Ms. Ferguson was very calm and allowed me to examine her. She denied any itching or other areas of rash or redness. She did state that she felt some pain when I touched her face. The affected area was confined to only her left forehead from just above her eye and into her left scalp. Could it be herpes zoster involving the first branch of the trigeminal nerve? I was getting a little excited. (I felt like one of those smart teaching attendings with an interesting case at the university.)

The area was reddened, but no vesicles were visible. There was no real edema per se, and it wasn't really that tender. It just didn't look like zoster to me. I looked over the rest of the patient and found no urticaria, no erythema, no nothing.

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