Introduction: Documents in the medical chart have a certain structure and flow, whether it is a History and Physical (H+P), consult note, or daily progress note. This helps health care providers communicate quickly and clearly in a standard fashion (with varying degrees of success). I tried to imagine what my H+P in the chart would look like, and that’s in bold. The rest is my response to my own H+P. Call this creative writing, or maybe just writing. Pictures are generally not included in an H+P, but this is my blog, so anything goes.
Chief complaint: aphasia
Every health care provider’s note should start with a chief complaint, or a reason for the visit. The chief complaint is why the patient presented, ideally in his or her own words. It should answer, ‘why did the patient come here today?’ I have listened to patient presentations, but still had no idea why the patient was actually here that day. Yes, the diabetes, hypertension, and a prior myocardial infarction are all important, but what made him walk through the door?
My chief complaint October 29, 2015 was inability to speak. That’s aphasia. I was aware of my problem, but did not understand it. But let’s not get ahead of ourselves. The details belong in the history of present illness. There, the provider has a chance to shape the patient’s story into a coherent narrative and argument.
History of Present Illness: Dr. Craig Alguire is a pleasant 39 year old man who presents to the emergency room after two episodes of aphasia.
I never had the patience for adjectives like ‘pleasant’ or ‘wonderful’ or ‘delightful.’ I keep it blank for everybody. Play it straight. What if a positive adjective could not be mustered? What would a blank space reveal? And who wants to be just ‘pleasant?’ Also, I type my notes, so my fingers appreciate brevity.
He was a previously healthy 39 year old.
Previously. That’s an word ominous in the History and Physical genre. It means the history will be easy to take, no confounding variables, but gives the note a sense of foreboding.
He was active, doing some form of exercise each day. In fact, the first episode of aphasia occurred while he was on his stationary bike.
No, I was the healthiest 39 year old I knew. I had a birthday a week prior to symptoms onset. I exercised with some degree of intensity for at least an hour a day. I loved the feeling of pushing it too far, even feeling a wave of exertional nausea. I was making a training schedule in my head to improve my 6:00 minute per mile pace to 5:48 at the 2016 River Bank 25K. I can tell you now since I don’t have to live up to it…I was going for sub 1:30. Probably could not do it, but the plan was my distraction. My hobby.
Figure: On the left, finishing the RiverBank in 2013, caught by the camera as I was trying to figure out where to meet Staci after the race. In the middle, a selfie on my bike trainer. A view I would need to see much more of to improve at triathlons. On the right, Masters swim practice 11/2/15. Andrew Maternowski, me, Danielle, and a rare Jeff Flermoen siting.
I was on my trainer on a Thursday morning. Since that date was very memorable, I can add a great deal of specificity: that would be a P2 Cervelo bike on a Kurt Kinetic trainer at 6:00 AM. I was watching HBO GO with my parents’ password on my iPhone 6 Plus. I was 10 minutes into it, and I felt the urge to talk, but could not. I could only form a stuttering, “I..I…I…I” and then it resolved within 30 seconds. I mean completely resolved. It ceased. I felt the urge to take a deep breath, and I could talk again. So, after I walked upstairs for a water break contemplated calling my wife at MVP, I just got back on my trainer, and then ran a mile on the treadmill. All systems seemed to be a go. No gross neurological defect, no gross indication not to go to my clinic.
I ran through a differential diagnosis in my head, or a doctor’s list of possible causes of a particular problem. My limited differential included stroke, mass, seizures, and anxiety. But why so focal and brief? Stroke would be the most common cause of aphasia, but I was at a low risk for a stroke, even if paroxysmal atrial fibrillation were present. My blood pressure was borderline but fine, and cholesterol, although with a low HDL, certainly did not raise suspicion of early vascular disease. Dissection of one of my cerebral arteries could cause intermittent symptoms, but that would be such a focal dissection and so rare. I did not smoke, so stroke just did not make sense.
I actually did consider a mass, but why intermittent symptoms, completely resolving? And I actually thought if present, probably no rush to get this diagnosed. ER door to cancer diagnosis time was not a marker of quality (as we have fixated on in cardiology for acute myocardial infarction care). And then I thought about all the weird and inexplicable symptoms patients over the years have told me about. A mentor of mine just suggested to acknowledge those, but do not try to explain the inexplicable. So off to work I went.
Dr. Alguire went to his went to his clinic, and felt fine. At the last patient appointment for the morning, the symptoms occurred again. The patient stepped out to get the nurse, and EMS was called. And again, the symptoms resolved within 30 – 60 seconds.
That’s when I realized something was wrong, and I could no longer be in denial. I actually told Staci about initial symptoms prior to leaving for work, and sort of shrugged. She suggested I tell someone at the office, and I did (Jeff Decker and Tom Boyden). They suggested a few cardiovascular tests because we are in a cardiology clinic (echo, carotid dopplers, etc), but I was willing to do a ‘watchful waiting’ approach.
I was consciously aware of my typing with patients throughout the morning, and how ‘normal’ it felt to make multiple mistakes at 50 words per minute. The older doctors would kill to navigate our electronic medical record EPIC at this speed. I texted my wife at 10:59 AM, “Still alive, feeling fine.” On my last patient prior to heading downtown at the Meijer Heart Center, it happened again. I stuttered a few times, and my patient assumed I was nervous (he was 6’5 police officer, so maybe he gets that a lot on the job).
“It’s okay, just relax,” he said. I flipped over his EKG and wrote, “I can’t talk.” He jumped up to get my nurse practitioner, and it was like a code blue was called. I was ushered to my desk, given 4 baby aspirin (for a presumed stroke), an EKG (sinus rhythm), and EMS was called. Again, I was fine within 30 seconds…but not really.
You can write off one episode of something weird, a second one prior to lunch needs to be explained. And it was witnessed by a bunch of well trained medical providers. I called my wife to tell her it happened again, that I was fine, but she needed to meet me at Spectrum Butterworth Hospital. So much for watchful waiting.
I left my desk on at pod C by a stretcher, but I could have outpaced anybody to the ambulance. Nothing like leaving your primary site of work by ambulance to arrive at your other ‘office.’ My nurse Jane Ballard could even see me being loaded in to the ambulance from the second floor and texted me to get off my phone. After calling my wife, my second call was from one of my older sisters, Katie. She is an oncologist, as if fate was playing tricks with me.
He presented to the ER feeling fine and back to baseline.
I arrived by stretcher, but I could have biked from the office, or maybe even run the few miles faster than the roundabout way we drove.
Past Medical History: None
The last physician I saw (besides myself in the mirror every morning) was my pediatrician. My dad used to just fill out my sports physical without doing the exam (no turn your head and cough). It would be filled with smart ass comments like, ‘poor exercise tolerance,’ or tends to ‘whines with excess exertion.’ Those were the days when we took those sports physicals less seriously, I presume, because nobody questioned it.
Okay, a couple of ibuprofen every few weeks for a headache.
Although I did tell ER doctor Trevor Cummings I was allergic to Tylenol and NSAIDs, but that medicine that started with D seemed to always work well for me and my pain (okay, that is an insiders joke). I felt fine, did not need anything.
Social History: Does not use tobacco products, drinks 5 beers a week. Cardiologist. Married, 4 kids. No illicit drug use.
The social history is what and who you are, but gets boiled down to smoking and alcohol for the most part in the Emergency Room. Not included: married his high school girlfriend, and no other really serious girlfriend. I still look furtively over my book at night while she changes into her pajamas and smile like I was getting away with something.
Family History: non-contributory
Most of family history reported by patients is non-contributory, but may give insight into anxieties. Father died of cardiac arrest at 69? You are 68? Noted. Primary brain tumors generally do not have a family history. In fact, two cases of GBM in one family still appears to be chance more than hereditary. Anyway, my family history was benign.
Review of Systems: Reviewed 10 out of 14 systems, and negative except as mentioned above.
I will have to admit, I probably don’t know 14 systems, and why only 10 of them are generally reviewed. This is primarily for insurance purposes.
Physical Exam: 170 / 95 mm Hg, pulse 80 bpm, respirations 12 per minute, 98% pulse ox on RA.
General: no acute distress
HEENT: no jvd, no carotid bruits
Pulm: clear to auscultation
Cardiac: RRR, no murmurs / rubs / gallops
Pulses 2 + throughout, no edema
The physical exam is probably overly emphasized in the minds of patients, where physicians know the bulk of diagnoses come back from the History of Present Illness. But I do believe in vital signs, and I was hypertensive. Despite my calm outward appearance, I was in fight or flight mode.
This is where a formal case report or presentation would pause and state “a diagnostic test was performed.”
Non-contrast head CT: Moderate localized mass effect with subcortical attenuation, centered at the superior gyrus of the left frontal lobe….Neoplasm is the primary differential consideration.
My cardiology consult, colleague and friend broke the news. This was not a stroke. Unbelievable when you are disappointed with that realization. As most radiology reports conclude, this one suggested a second study.
MRI Brain W+W/O Contrast: There is an aggressive appearing, enhancing mass lesion…evidence of hemorrhage with the lesion. High-grade glioma is thought most likely.
Figure: My MRI, my brain, my tumor.
I do not remember the receiving the news, one of the few things I do not remember from that week. I only remember hearing the neurologist’s footsteps coming down the hallway, pausing for about 10 seconds in hallway, and Katie weeping. Put that in the ledger of a bad prognostic findings when your sister the oncologist is openly weeping prior to breaking news.
Assessment and Plan:
Dr. Alguire is a 39 year old ‘pleasant’ man who was ‘previously’ healthy presented with episodes of aphasia and a new diagnosis of brain mass most consistent with a high-grade glioma.
Brain mass: differential includes primary brain cancer (high grade glioma) and metastatic disease. Infection also possible.
-steroids and anti-seizure therapy with Keppra
Aphasia: likely secondary to partial seizures
Any good internal medicine note will have a differential diagnosis. As patients like to say, “I am not a doctor, but…” Well, I am a doctor, but not a radiologist, neurosurgeon, or pathologist (the proper pathway for a diagnosis of a brain mass). However, I looked at my scans and winced. This was brain cancer, and almost certainly glioblastoma grade 4 (or glioblastoma multiforme).
Nobody needed to tell me what my oncologist sister Katie,did not already say by crying in the hallway. There was a golf ball sized mass in my left frontal lobe anterior to my motor cortex. This is the area of the brain that controlled the right side of my body. Irritation locally caused a focal seizure involving the nerves controlling my speech.
“No symptoms?” Not until today. Felt great in fact.
And so I was admitted. My medical journey probably began on my bike that AM, but it felt acute on the hospital room. This is where my journey as a physician — from a family of physicians — started as I needed to navigate the health system from the other side. I was admitted to the hospital, but staying in the hospital is miserable and of no utility in our opinion. My sister was already communicating with a neurooncologist at the University of Michigan while my scans were being read. Really, this was not an emergency. I was not having unstable neurological symptoms, and there was no evidence of increased pressure in my brain. By the time I settled into my room, I had an appointment scheduled the next day at 9 AM at the University of Michigan with Dr. Shawn Hervey – Jumper. We only had 1 recommendation, but he sounded professional and accommodating on the phone. I took my decadron and Keppra prescription, and asked for discharge while the hospitalist did his intake History and Physical.
My sisters were in the room with parents, Uncle Jim and Aunt Joyce in addition to Staci. I’ll just remember my Aunt Joyce, Grandma Alguire’s younger sister, saying she would switch spots with me if she could. I knew it was true, so I cried for the first time. Not for me, but just for the truth.