“When was your last bowel movement?” I asked.
“Two weeks ago,” the patient said. I glanced at the initial history and physical that my intern had given me, stating that the patient had diarrhea one day prior to admission.
“I thought you had diarrhea two days ago,” I said.
“Oh yes, it was very watery. I had to run to the bathroom six or seven times that day. Explosions every time.” He clapped his hands together, demonstrating the force at which his GI detonations took place.
“So have you had a bowel movement since that day?”
“No, not for two weeks. I already told you that.”
Thirty minutes of interviewing later, I finally discovered that Mr. M did not consider diarrhea to be a bowel movement, but rather “peeing from the buttocks.” My team had already rounded on him earlier that day; his diagnosis of dizziness due to diarrhea-induced hyponatremia did not foster interest from most of the team, but I had still volunteered to follow the case.
“Did you drink anything that day?” I asked.
“Yes, water.”
“How many glasses?”
“Fifteen. I drink fifteen glasses of water every day. Ever since I came to America,” he said. Mr. M had emigrated from Bangladesh eight years ago, was unemployed, and lived at the men’s shelter next to Bellevue. The history I extracted from him was no different than the history the intern from the previous night had taken, but needing the practice, I decided to perform a full medical student history, one that would take up the next two hours.
“Any history of depression?” I was near the end of my review of systems.
“I’ve always been depressed. Ever since I came here.”
“Ever since you came to the hospital?”
“America.” The glazed look in his eye was difficult to interpret. I thought I sensed sadness. My intern said it was retinopathy due to uncontrolled diabetes. “I came to America and was such a failure.”
Using a Bengali interpreter, I questioned Mr. M with a PHQ-9 scale. After enduring long,
foreign conversations that resulted in short yes and no answers and an episode where I was put on hold for ten minutes after the interpreter’s dog started barking, I finished assessing the patient’s depression. Mr. M scored an eighteen, giving him the oxymoron of moderately severe depression. “This is the first time I have ever talked about my pain.” He smiled for the first time.
“Thank you, my son,” he told me at the conclusion of my interview. “I always wanted a Hindu son, to show that Muslims and Hindus could get along.” I told him I was Christian and left. We started him on an antidepressant, called a psychiatry consult, and planned to discharge him the following afternoon.
The next day, Mr. M looked even worse. “Do you still feel dizzy?” I asked, immediately assuming that his initial chief complaint was his primary ailment.
“No, my son.” He had started to call “son” after our bonding session the previous day.
“What’s wrong?”
“I haven’t gone to the bathroom in two weeks.”
“But you had a bowel movement three days ago.”
“No, I haven’t done anything in two weeks.”
I decided against arguing with him about the definition of constipation, instead focusing on documenting what medications he was currently taking from the bag of pills his friend had brought in. Among the blood pressure and diabetic medications, I discovered two bottles of duloxetine vs. placebo from a clinical trial located in Staten Island. “Why do you have these?” I asked.
“I’ve never taken them. My friend just gave them to me.”
“But why?”
“I don’t know. He said they would make me feel better.” He hesitated. “Do you think these will make me go to the bathroom?” he whispered.
“No,” I said, confiscating the bottles without any complaints.
On work rounds, I told the team about the bottles of clinical trial drugs. In summing up Mr. M’s case, I stated that psychiatry should be called again to see him. “And maybe we can give him a suppository,” I suggested. My resident shrugged me off, put in an order for bisacodyl per rectum, and hurried off to see the next patient.
When I saw Mr. M later that day, he was beaming status post bowel movement. “I feel so happy. You cured me. I’ve gone to the bathroom so much!” he exclaimed.
“Did psychiatry see you?”
“They were waiting for me after I came out of the bathroom. Nice people.” He was gathering his belongings. “I was told I could go home today.”
“You look much better.” I smiled and started to leave, another patient discharged without me having to do anything.
“Doctor, wait. Do you think…do you think I could get a prescription for the rectal thing? It’s changed my world.”
“I’ll see what I can do. Take care,” I said, leaving him for the last time.
I went to a nearby computer to see what the psychiatrist had said. “Patient is oriented x3 and appears well. Does not report any depression. Would advise that patient discontinue antidepressant that medical team started. Patient can follow-up with outpatient psychiatry if desires.” Translation: the medical student does not know what he is talking about.
The case of Mr. M demonstrates that so much of medicine is subjective and based on the personal relationship that a physician builds with his or her patient. Psychiatry may have concluded that Mr. M was better after clearing his bowels, but I remain unconvinced that constipation is at the core of all his problems. Of course, it is entirely possible that I am wrong, as psychiatry’s note indirectly points out. I may have misinterpreted diabetic retinopathy as sadness, but I can always blame my Bengali interpreter if I was indeed incorrect.
