By Dr. Anthony Policastro

I was recently reading a pediatric article about a 9 year old girl. She came in with arthritis of her ankle, and the history failed to reveal anything that would suggest a cause of an inflamed ankle.

They took fluid out of the ankle, it was clearly infected. They gave her antibiotics and the ankle got better. Ultimately the culture of the ankle grew out the infecting bacteria. It was a bacteria that causes rat bite fever. When they talked to the family, it was at that point they mentioned that she had two pet rats and one of them had nipped her.

Sometimes patients do not understand the importance of giving every bit of information. In a case like this, it would not have made a huge difference. She still had an infection, and it still needed an antibiotic. That is not always the situation.

When I was at Andrews Air Force Base, we had a patient sent to us from another base. He was a six week old with a condition called pyloric stenosis. This is a common pediatric condition. It is easily cured by surgery. The history as given by the parents did not reveal anything out of the ordinary.

He had the surgery and was being treated as an inpatient on the surgery service. That evening at 2 a.m. I received a call from one of my pediatric residents. He told me that the patient was going downhill.

I rushed to the hospital. We were doing the resuscitation. As we gave fluid, the abdomen swelled up. We put a needle into the abdomen and drained what appeared to be bloody fluid. There was obvious bleeding.

The parents came in from the local hotel and we told them about the situation. As the intern and I were leaving the room, they turned to us and said “By the way.” Those are words that often do not have good things following them.

Their next sentence gave us all the information we needed. “Does it make any difference that there is a family history of hemophilia?”

The resident had asked questions about family history and that was never mentioned. Apparently the grandmother had two husbands. The son born of her marriage to her first husband had hemophilia. She had two daughters by her second husband and they were both fine. Therefore, the assumption was that the first husband was the carrier of the hemophilia.

That assumption was not correct. Hemophilia is carried by females. The grandmother gave it to her son by the first husband. The mother of the patient we were treating was a carrier because she got the gene from her mother.

This occurred during a time when circumcisions were being discouraged. The child had not been circumcised or we would have made the diagnosis earlier.

Unfortunately, the resuscitation was not successful. The parents had the necessary information but they did not think it was important. The little girl with the pet rats had the information but the family didn’t think it was important.

Patients who give a history need to understand that there might be things that they do not see as important that might indeed be very important. It is best to not leave anything out. That is especially true when the diagnosis is difficult.