Tracey Quail Davidoff, MD, FCUCM
I was scanning the tracking board during an urgent care shift the other day and, as usual, my brain was five steps ahead. I read the chief complaints and had already determined the questions I’d ask to guide the history based on the differential diagnoses I’d predicted. This is a regular occurrence in the UC and ED, whether we admit it or not. It’s part of how we move things along—thinking a few steps ahead.
I was seeing a patient whose complaint was “Foot pain—ball of foot. No injury.” Already I’m working on the possibilities: plantar fasciitis, callus, poor footwear, metatarsalgia. I started asking questions, “Old shoes? Worse in the morning when you first wake up? Better with stretching? Worse at end of night?” Yes, yes, and yes. I glanced at her foot, saw a callus, and a plantar wart. She’d had trouble with the callus before. “Meant to call the podiatrist…I keep forgetting,” she told me.
The callus and the wart were tender, but not red or warm. The foot hurt when I dorsiflexed the toes. Then I noticed some old bruising under the little toe. “You sure there was no injury?” I asked. “Well, maybe,” she replied. Hmmm…now there were four possibilities.
I could have diagnosed plantar fasciitis, contusion, callus, and plantar warts and called it a day. In and out in 30 seconds or less and on to the next patient. But for some reason I felt compelled to look at her foot more carefully.
I got a magnifying glass to examine the plantar wart. After some poking and prodding, I was shocked to find that the “plantar wart” was actually a piece of glass embedded in the sole of her foot. Then it hit her. She suddenly remembered walking barefoot in her garage just before the pain started. Oh, and then there was that pickle jar she had dropped out there a few weeks before that she remembered next. I removed the glass with tweezers, and the patient was instantly asymptomatic.
And what is the point of this story, you may ask? So often our shifts are rushed and overfilled as we are pressured to see patients faster, respond to administrative concerns, keep up with our various inboxes, and the list goes on. I know providers that write up discharge instructions and prescriptions based on the chief complaint to save time before even seeing the patient. Others barely ask more than one or two questions, relying almost entirely on the triage information recorded by the staff or patient intake forms. For COVID concerns, I’ve seen colleagues walk into the patient’s room and just say “negative” and walk out without taking any history at all. Some patients are barely examined.
When we have to see four to six patients per hour and complete all the required documentation, it is tempting to cut these corners in the interest of time.
But what of quality of care? Patients don’t always describe their complaints fully or accurately to our support staff. Often the chief complaint is entered by a secretary or MA and not the patient. “Shortness of breath” often turns out to be nasal congestion, “chest pain” often is stomach pain, a “UTI” may be genital herpes, and “sore throat” can actually be neck pain. Foot pain and ankle pain are confused often. I’ll admit I’ve preordered the wrong x-ray based on chief complaint in these cases more than once.
This case demonstrates the value of even a slightly more careful physical exam. A mentor once told me that 80% of diagnoses can be made on history alone. Although I find that is often the case, there is no substitute for careful inspection. I have caught abdominal aortic aneurysms in patients with back pain, pulseless feet in patients with blisters on their toes, shingles on patients with chest pain, and fractures in patients who supposedly hadn’t had any injury.
All of these diagnoses, just like the piece of glass in the foot, would’ve been missed had I not taken that brief extra moment and done a little extra digging. Certainly, with all the pressures we face in UC, it’s easy and tempting to do as little as possible. But I want to challenge you to take that extra minute and dig a little deeper. You might be surprised at what you find, and your patients will thank you for it. Just like that woman with the piece of glass in her foot did as she walked out of my clinic without the limp that she’d hobbled in with.
Tracey Q. Davidoff, MD, FCUCM is an attending physician with BayCare Urgent Care in Tampa, FL and a member of the JUCM Editorial Board.
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