What Do Doctors Do When They Have No Idea What's Wrong With You?

As a doctor, what do you when you have no clue how to treat a medical problem? originally appeared on Quora: the place to gain and share knowledge, empowering people to learn from others and better understand the world.

Answer by Lou Davis, works in Emergency Medicine, on Quora:



Way back, in the annals of time, a young man was brought into the Emergency Department.

His presenting complaint was that he was ‘unwell’. The relevant history was that he had spent the previous evening imbibing heavily of alcohol and had slept where he had fallen - the kitchen floor.

He looked, it has to be said, ghastly; ghostly white, sweaty. As my Gran would have put it ‘like death warmed up’. His blood pressure and heart rate were, relatively, normal. His temperature was good.

For want of something better to do, we examined him closely, for clues as to the malaise which affected him. For he was certainly unwell.

The thing about medicine is that it, usually, gives clues; the clinical history is the starting point - how has this person ended up in this state? The clinical history leads to suspicion. Suspicion leads to a thought about the investigations required to reach a conclusion.

The possibilities form the differential diagnoses - the ‘options’ from which to choose.

The options in this case related to the history given.

Was the young man merely suffering from the after-effects of a vast quantity of alcohol? Was he suffering a hangover? Had he taken drugs? Was he dehydrated? Had he fallen and injured himself?

The examination, and the investigations allowed each option to be ruled in, or ruled out. Each piece of information is connected with the other information gathered - forming a clinical jigsaw puzzle.

Initially, we ruled out the most common, the most likely causes of his symptoms. Gut instinct is a valuable thing. If someone looks unwell, generally they are unwell - until proven otherwise. While we waited for the pieces to slot together, we treated the symptoms - the nausea and vomiting, the apparent dehydration. We started an intravenous infusion, administered anti-emetics for nausea. We noted his blood pressure.

Persuaded him to pass urine into a pot and tested it - suspicion already forming the glimmer of an idea.

There was our eureka moment- the urine sample tested positive for a substance which can result from lying in one position for too long.

The simple act of remaining in a drunken stupor for many hours, lying on a hard floor had resulted in a life-threatening illness. It is not an exaggeration to say that, at this point, the patient was the sickest person in the hospital.

His life was in the balance. His organs were failing. There was a strong possibility that he may not survive the illness.

His diagnosis?

Rhabdomyolysis.

He spent almost 3 months in the Intensive Care Unit - extremely sick.

But he survived.

It is very rare that we don’t know how to treat something. Mainly because the first principle of medicine is to treat the symptoms whilst trying to find the cause. Even if it is impossible to be certain what has caused someone to be unwell, it is usually possible to treat the presenting symptoms.

Medicine is like a mystery; put the clues together and diagnose based on the results of the examination, the history and the investigations.

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