History and Physical

"The cause is hidden, but the result is well known." -Ovid, Metamorphoses

Sometimes the doctor has to struggle to earn his money. A true story:

"Sit down, Mr. Robinson . . . Yes, right there . . . Now, what do you complain about?"

"It's my back."

"How long has it been bothering you?"

"A long time." (There's a definite answer for you.)

"Oh, sure, but that's from when I broke my leg in 1946 and infection set in and I had to have the bone scraped." (Something new has been added-he didn't count that as an operation or a serious illness.) "Does it interfere with your sleep?" "No."

"Does it hurt when you cough or sneeze?" (I'm still

"How long, would you say? A month, a few days, six on the disk deal.)

%%,eeks?" (Polite, but insistent.)

"Oh, it isn't steady. It comes and goes." (Getting nowhere fast. Might as well give up the chief complaint approach and try the personal history.)

"What kind of work do you do?"

"I'm not working now."

"Well, what kind of work did you do?"

"All kinds, sort of general, you know." (I don't, but the question wasn't too important anyway.)

"Have you had any serious illnesses or operations?"

"_just tonsils, when I was a kid."

"Now, when did you first have trouble with your back?"

"Well, it started off slow-like and then it got worse, so I used some stuff my mother-in-law said was good, and it went away. But then it came back, so I went to the drug store and Mr. Schneider there, he gave me something to put on, but that burned too much so I just used compresses, and then it went away again, but then it came back one day after I was bowling and I think I must have caught a cold or something there-they have this bench right against the outside wall, and it's always cold from opening and closing-and then it went away by itself, and then. . . ." (He's talking at last, but so far be hasn't said anything. Time to put a stop to this.)

"Does it hurt when you bend?"

"No."

"Do you have any pain down your leg?" (Sorting through the causes of intermittent backache in my mind, I consider a protrusion of the intervertebral disk.)

"And how! But only sometimes, when I have the pain, that is." (I'm making no progress at all. Better give this up and try the direct method.)

"Point to where the pain is."

"Oh, I don't have any pain now." (Touche'! I used the wrong tense.)

"When you do have the pain, exactly where is it?"

11 Right here in the back of me." (Waving a band in the general direction of his posterior from the neck to the end of his spine.)

"All right. Go into the next room and strip." (I give up. I know when I'm licked.)

I note scattered black and blue marks on his thighs. "Did you fall recently?"

"Uh, no, Doc. Those marks are from where I take the needles-you know, for my diabetes." (He didn't count that as an illness, either. )

"How do you regulate your dosage?"

"I go by the urine test and whether I feel itchy. My wife says maybe I scratched myself and that's how I hurt my back originally." (I get the mental picture of the poor man reaching around to scratch at an inaccessible place and getting a backache. No sense talking any more. I go through the whole routine: checking blood pressure; listening to heart and lungs; looking at the throat, eyes, ears, nose; palpating the abdomen; testing the reflexes verything but a rectal examination-before I get to his back, which I go over thoroughly.)

"No limitation of motion, no muscle spasm, no sign of any spinal trouble," I tell him.