The one among many

It is December break and most of the physicians at the clinic are away this week. My days are left open for “same-day urgents” only. No well-baby visits, periodic health examinations, routine counseling—these can wait. The phones start ringing at 8:00 sharp and I ask our secretary to tell patients who need to be seen to come now; the day will only get busier as the hours pass. Gastroenteritis, strep throat, otitis, influenza, more gastro, sinusitis—all the infections of the season come through the door in various demographic representations. Fluids. Rest. You don’t need antibiotics. You’d better start antibiotics. We’ll await the swab. I’m going to treat you anyways, without the swab results. It is as if I am reading a script—different parts at different times, depending on the various presentations. And doing the same quick review of systems with every patient, time and time again.

Then in walks Mr S. He is 56 years old, with a persistent cough following a viral illness. He can’t sleep because he’s coughing. I’ve seen 8 patients with similar presentations already today. He looks well. Mild, controlled hypertension. I do a quick review of systems. He says he has had some mild chest discomfort from the dust he has been inhaling while doing renovations in his house. I pause, rewind, get the details slowly. This pain started 2 weeks ago. No previous history. Burning. Occurring with less exertion these past 2 days. Exam findings are essentially normal.

I face him.

You need to go to the emergency department for assessment.

Really? I just want something for my cough at night. The pain is from the dust—it’s irritating me.

You have to go.

Mr S. goes. His electrocardiogram is abnormal and the subsequent angiogram shows 95% stenosis. Stents are inserted 24 hours later. His wife calls me—forever grateful.

I reflect on the week, which has been full of patients with acute, self-limiting illness. Some patients required medications; most were recovering on their own, needing only reassurance. Many children with anxious parents. Among them all, one person presents the same as the others but with much more serious disease. This is the one we cannot miss. This is why we do the same review of systems on every patient, no matter how straightforward the case appears.

Of all the patients we see, by far most will be just fine if we send them home, except for the one who won’t.

We do our best not to miss that one.

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