Classic presentations

If medical school teaches you one thing about disease processes, residency will teach you another. Take for example intussusception (the telescoping of a proximal segment of bowel in to a distal segment). Medical school teaches numerous mneumonics and classic presentations such as abdominal pain, vomiting, and currant jelly stools (whatever that means) however, in residency you learn that only a small, very small percentage of intussusceptions present that "classic" triad.

A real life example: two weeks ago I had a patient sent from an outside urgent care clinic with periumbilical abdominal pain that later shifted to her right lower quadrant. She was nauseated, had been vomiting and had a positive Rovsing's and Psoas sign. The clinic that sent her knew she had appendicitis. I knew she had appendicitis. The CT scan, however, said she didn't.

So where does that leave us. Typical presentations commonly present atypically, and uncommon presentations typically can be common.

Yesterday I had a 24 year old present in tears, almost screaming in pain form her headache of acute onset. She could barely answer the questions I was asking, and if medical school taught my anything, its that in that situation there is really only one question that needs to be asked: "Is this the worst headache of your life?"

"YES!", she screamed emphatically. Off to the doughnut she went. Not much time had passed before I got a call from the radiologist. Anytime that happens you know its bad, and in this case I knew what happened. She popped an aneurysm. She was sent to the operating room and actually ended up doing well. There were a few post-op complications, but she was eventually discharged back home at her baseline.

In this case, all the mneumonics and classic presentations actually correlated to the disease process. So I guess they are good for something, just not all time (or maybe even a fraction of the time).