Dear Dr Crippen
The hospital manager has asked me to respond to your letter of complaint about your consultation with me last weekend;specifically your complaint that I failed to order a chest x-ray and/or insert a chest drain.
I appreciate that your ribs were painful after you fell against the edge of the loft door,the day before,and as I said at the time,it is entirely possible that you have broken a rib-that is why both the triage nurse and I offered you some analgesia,particularly since you hadn't taken any since the accident happened.
I do also appreciate that your husband thinks that only wimps take analgesia;that he refused to give you some paracetamol;and that you feel he treats you like a child-but research has shown a direct correlation between taking Gods' own dose of codeine and not turning up at my hospital wanting me to perform a major invasive procedure on yourself.
Perhaps,-after you have seen the marriage guidance counsellor-,you could ask your university for a discount?
Unfortunately the fact that your husband is apparently a world renowned ENT surgeon;and that you are apparently an equally world renowned Dermatologist ,does not in and of itself meet the criteria to allow me to either order a chest x-ray or insert a chest drain.
There is a well researched and thought out protocol for dealing with rib injuries,which is common to the NHS and indeed to the Strategic Health Authority area in which you,your husband ,my manager and I all work.
When I start to examine a patient who potentially has a serious or sinister presentation,I approach the diagnosis much like assembling a jigsaw puzzle to which I have no picture.
So,sign-by-sign,symptom-by-symptom,finding-by-finding,I start from a basic initial premise suggested by the history;and then go looking for the center of the metaphorical picture-the clinical impression.
I see from my notes that you had some slight bruising over your 7/8 ribs in a 2cm area on the left axillary line.I also see that your oxygen saturation was 100% on room air;that you were talking in complete sentences;were normo-tensive;not cyanosed;and had had no heamoptysis.
So whilst its fair to say that there was no single thing that predisposed me to thinking that you did not have a pneumo thorax its fair to say that after hearing you shouting at the triage nurse for 5 minutes,that I did have some idea about what my examination would find.
You might remember that you also told me that you had gone horse-riding for over an hour after the accident.
But I think the significant part of the history was when you told me that you had taken part in a 30 km bicycle race that morning.
PS. I think that your complaint about Studdley McMuffin,the admissions clerk was unwarranted.I know that both Julian and UglyJulie find him physically attractive,but to describe him as a vacuous headed pretty boy is unfair and demeaning.
He is a thoughtful and interesting young man who has a great future,somewhere else,doing something else.His description of you as "an old lady with broken ribs" was meant as a 'clinical heads-up',and was not a reflection on your desirability as a sexual playmate.
PPS.Really...see a shrink!