When the history was 100% of the diagnosis

It is 3:30am. A 17 year old  girl is referred to AMU for lower left rib/chest pain. The nurses have been unable to bleed her. I was asked to try bleeding her. I decided to take the history and do the examination before taking blood.

I was greeted by a crying girl who keeps saying she just wants to go home. She was referred by her GP to A&E. She is hostile to your questions, and gives minimal answers. The pain has been there for two days, and it anything is better now than it was when it started.  It started gradually over many hours. It waxes and wanes, but never disappears completely. It is localised to the left lower ribs. It is not affected by breathing. She only sleeps on her left, as sleeping on her right stretches the area, which brings on the pain. Lying down brings on the pain. Sitting up relieves it. It is not worsened by inspiration, and there is no shortness of breath at all. There is no cough or fever. There is no leg swelling or tenderness. She has had a similar episode before on her right, when she slept in a funny position. There is no history of trauma. There is no history of long distance travel, and she does not take the COCP.

She has been in theatre rehearsals recently.

On examination, there is nothing remarkable. There is no chest wall tenderness, and she is saturating at 99% on room air with a respiratory rate of 16. The pulse is 78, and BP 108/77. She is afebrile.

The referring doctor from A&E requested FBC, U&E, CRP and D-dimer. He also requested a chest xray.

My differential consisted of musculoskeletal pain, musculoskeletal pain and possibly musculoskeletal pain. I could not think of any investigations that were really needed, as I had no differentials to rule out. I certainly did not want to do a D-dimer, as if that came back positive we would be forced to subject a young girl to a V/Q scan or CTPA.

Not doing any investigations at all on an A&E patient is pretty brave/stupid, depending on your point of view. Still, I somehow felt quite confident in my decision. The patient seemed at risk of becoming disillusioned with medical services the longer she stayed in, especially for repeated attempts at a blood test. I had been clerking a patient in the next cubicle, and could hear her crying loudly at the repeated attempts. I felt that she needed to go home, and the time I saved on not doing bloods/chest xray would be probably be better spent making her and her companions hot chocolates to ensure she has a positive outlook on healthcare professionals.

The father and her brother were with her. I told all three of them what I thought, and explained the very small risk of a clot on the lungs. I explained the consequences of not doing the test. I explained that if we do not do the test, she should come back if symptoms persist more than 48 hours, if they worsen, she develops shortness of breath or generally feels unwell. I asked the patient if she wanted to press ahead. She was well informed, and made an informed decision with capacity to refuse blood tests.

Once she knew that she was not going to have blood tests she became much happier. We discussed her drama production, Family Guy, and how they could make the hospital cubicles for each patient more interesting. I also made sure they got their hot chocolates before they left.

As I double checked my plan with the registrar before letting her go, I felt deeply satisfied. I feel the nature of A&E may make us unnecessarily cautious at times. There was a good chance this decision had saved her a radiation dose and an overnight hospital stay. She was smiling as she left drinking the hot chocolate. I had never felt happier for cancelling a d-dimer.


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