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Until a couple years ago, when I was probing about pleuritic pain, I would ask:
“Does the pain get worse with breathing?”
But then..
1/
“Does the pain get worse with breathing?”
But then..
1/
I started noticing that I was getting a lot of “false positive” responses.
Many of the folks answering this question have both chest pain and shortness of breath... that tend to come together.
2/
Many of the folks answering this question have both chest pain and shortness of breath... that tend to come together.
2/
“Is the pain worse with breathing?”
Stop.
Imagine being that patient. And look again at the words of that question above.
“Mmm.. yea.”
“But does breathing make the pain worse?”
“No.”
3/
Stop.
Imagine being that patient. And look again at the words of that question above.
“Mmm.. yea.”
“But does breathing make the pain worse?”
“No.”
3/
That last version is better, but it can lead to false positives too! When you associate the pain with being aware of your breathing, it’s not a leap to feel like one exacerbates the other.
For that reason, I have started to ask about pleuritic pain another way.
4/
For that reason, I have started to ask about pleuritic pain another way.
4/
Ask the patient to take a deep breath with you. “Like this,” say, inhaling deeply, neither too slow, nor too fast.
And watch their face.
5/
And watch their face.
5/
Sometimes the grimace and the catch (let’s call it the pleuritic Murphy’s sign) are all that one needs to see.
If they look ok, ask, “did that hurt, or catch?”
If yes, follow, “and is that part of the pain you were telling me about?”
But if they say no,
6/
If they look ok, ask, “did that hurt, or catch?”
If yes, follow, “and is that part of the pain you were telling me about?”
But if they say no,
6/
Consider the possibility of an episodic nature of the pain (e.g. in pericarditis, where it can vary over time, with position etc)... and still ask:
“But when you were having the pain before, would taking a deep breath like that have caused or worsened the pain?”
7/
“But when you were having the pain before, would taking a deep breath like that have caused or worsened the pain?”
7/
Certain features of symptoms have excellent test characteristics and can significantly narrow or reframe the differential.
But not if they’re a product of miscommunication.
Taking a history is a complex skills that should continue to develop over decades.
8/
But not if they’re a product of miscommunication.
Taking a history is a complex skills that should continue to develop over decades.
8/
Subtle wording differences, and the (mis)understanding they lead to, also explain many instances of this universal experience
.
In this skit, @DGlaucomflecken is brilliant not only in his satire but his questioning...
But most of the time, it’s how we asked the question.
9/9 https://twitter.com/DGlaucomflecken/status/1335304720311746561
.In this skit, @DGlaucomflecken is brilliant not only in his satire but his questioning...
But most of the time, it’s how we asked the question.
9/9 https://twitter.com/DGlaucomflecken/status/1335304720311746561
