It was just before the evening surgery. One of those nights when the partner who usually shares it with you has the ‘flu’ and the previous message your wife had taken (before you arrived home for dinner) said that a child with abdominal pain was coming and would you see the child before the appointments. You hoped that something less dramatic and time consuming than the asthmatic in incipient respiratory failure, who arrived unannounced last week, would not turn up too.
The patient was a boy of 17, well until two days previously when he complained of mild sore throat. He had attended one of the partners and penicillin had been prescribed for tonsillitis. He had not been unduly sick until that morning when he had become restless and, during the afternoon, progressively more drowsy and somewhat disoriented. His father, a distinguished academic, wondered whether his recent failure in annual exams might have contributed to his general affect.
He was very drowsy, uncooperative and afebrile but with a dry tongue and no other abnormal findings apart from mild pharyngitis. There was no neck stiffness, no positive Kernig’s and no evidence of drug overdosage or adverse reaction. He had previously been an active, healthy young lad with no history of serious illness.
Standing at the foot of the bed with both of his parents, now joined by a sister or two anxiously quizzical, and the time being 20 minutes past an expected arrival at the surgery, it was obvious that a tentative diagnosis had to be made fairly smartly. Masked bacterial meningitis seemed a good bet, until it suddenly occurred to me that his breathing was a bit more stertorous than one should expect from his level of consciousness. But what really helped the diagnosis were three large, empty lemonade bottles on the bedside table—not the sort we used to get for fourpence with a penny back on the bottle when I was a boy, but these monstrous two litre disposable flasks. ‘Has he drunk those three bottles recently?’, I asked. ‘Doctor, he’s been drinking all the afternoon. I can’t satisfy him’, replied the mother. Rather unusual for somebody who is apyrexial. There was no family history of diabetes; he had no prior symptoms of thirst, loss of weight or polyuria; he was too uncooperative to get a specimen of urine and I have never been really confident of identifying the smell of new mown hay.
‘I’ve got a young man with diabetic acidosis.’
‘Oh yes’, answered the admitting officer, ‘a known diabetic I suppose, and I suppose you’ve tested his urine for ketones’. Under persuasion and somewhat reluctantly, he dispatched an intensive care ambulance with that air of resigned acceptance peculiar to all admitting officers and with ‘they’d have a look at him and see what they thought’.
An hour later he rang. ‘You were right; he’s got a blood sugar of 61.5 with a pH of 6.95 and a pCO2 of 11. What made you think of it?’
‘Lemonade’, I replied, ‘bottles of it’.
And bottles also clinched the diagnosis in the second patient.
She was 52, recently returned home from a metropolitan hospital whose reputation for management of infectious disease is international and whose ability to make rapid and correct assessments had, more than once, led at least one local practitioner to wonder how his tentative diagnosis could have been so far from the truth.
During the last year the patient had been admitted several times with ‘recurrent’ infectious hepatitis. Fifty-two is an unusual age for hepatitis of the infective type and frequent relapses are excessively rare. She was deeply jaundiced and had all the features of liver failure, which included spider naevi, gross hepatomegaly and the first really convincing liver flap seen in a clinical lifetime.
Excessive alcohol intake was flatly denied and her husband supported her, both when we were together with the patient and even more strenuously when we withdrew to discuss the diagnosis. The evidence against their statements seemed so strong that I suggested we look for it. Rooms and cupboards were searched, plus under the house and, finally, a very long back garden. Almost on the rear boundary was a shed, literally stacked to the roof with gin bottles. I looked at the husband, he looked at me and, without a trace of hesitation and with what seemed complete conviction, the answer came to my silent inquiry: ‘Oh those—she collects them for the Red Cross’. My remark that I was unaware that august society had gone into the bottle-oh business was received as frostily as my look when we first discovered the obvious aetiology.
He, of course, won. His wife died many months later attended by one of the other partners of the practice, and none of the family has seemed to need my diagnostic skills since.
Time was when any visit to the home terminated with an invitation to ‘use the fresh towel’ and a ‘new cake of soap, Doctor’ while management and treatment—and occasionally diagnosis—were discussed.
The patient apologised—the bathroom was out of action and would I mind using the kitchen. She was 47, had had a cough and fever for two or three days preceded by headache, her temperature was 104.8 °F (40.4 °C, metrication and its machinations had not yet arrived) and she had moist sounds in the chest localised to the right mid-zone.
That winter had seen a small epidemic of what we used to call atypical pneumonia—now known, of course, to be due to mycoplasma which, we all know, is one of the few chest infections in which treatment can be initiated with a reasonable chance that the antibiotic chosen will be the right one. The picture seemed to fit; a prescription was written and arrangements made to visit her the following day. She was too sick to see me out but ‘the kitchen’s the first door on the right, Doctor’.
A half-dozen or so parrots in their cages—one or two looking somewhat dispirited—are hardly what one expects to find looking up from washing one’s hands in a kitchen. I shot back into her bedroom asking how long she had kept parrots and if any had been sick lately. She replied that she sold them at work—a variety store now apparently branching out from its original practice of selling nothing over two and sixpence (about twenty-five cents)—and that she usually brought home the sick ones, two of whom had recently died.
It was the first and only case, confirmed by rising serum titres, of psittacosis I have seen and, subsequently, the least contentious claim for workers compensation in which I have appeared.
DISCUSSION AND LESSONS LEARNED
So, home visits waste time; make for inefficiency, incomplete clinical assessment and delay in diagnosis; and are really only an expensive form of medical care pandering to patients’ whims. But, as far as I am aware, the advocates of multiphasic screening have not yet programmed one of their mechanical devices to scan the patient’s immediate environment, occasionally to explore beyond it—or to wash its hands!