Ars longa, vita brevis

A young musician named Nick is surrounded by medical students in the 10th floor room of a Harvard teaching hospital. It is May, and these second-year students are no longer new to the wards. In roughly 4 months, they have learned the basics of history taking and physical examination-skills that embody both the art and science of medicine. The medical history-the story of the patient’s symptoms, past illnesses, and family and social history-provide the information that will be used to establish a working diagnosis and plan of medical care. In an era of advanced diagnostic technology, the skills that were taught by Sir William Osler over a hundred years ago remain a cornerstone of medical diagnosis. Nick presented to the emergency department (ED) with a severe headache and a stiff neck. He had been in good health up until the previous day, when he noted a nasal discharge and a mild headache. He had never been seriously ill in the past. He took no medications. He did not use recreational drugs. His sister had died of a cerebral hemorrhage in childhood. Nick has played the drums since he was 10 yr old and has played professionally in a number of bands over the years. His income as a bicycle courier, however, is less than $1000 per month-enough to pay for food, a loft space, and child support but not health insurance. Only upon the urging of a close friend did he finally agree to come to the ED. It is likely that Nick might not have survived had he delayed any longer. As it is, he has lost part of his vision and will be in the hospital for weeks to come. Nick has an extremely rare genetic disease called Osler-Weber-Rendw syndrome, which has led to arteriovenows malformations. In his sister’s case. these malformations in the blood vessels of her brain led to a fatal cerebral hemorrhage. The arteriovenous malformations in Nick’s pulmonary blood vessels, coupled with a minor infection, led to meningitis and small abscesses in his brain. It will take precisely the sort of expertise and technology available at a tertiary care hospital to ensure that Nick will recover and suffer no further relapses. “How did the patient appear on presentation?” The On the wards, medical students learn that the social students’ preceptor attempts to teach them a key diaghistory is important in the formulation of a therapeutic nostic skill-how they must learn to recognize a critiplan. They are asked to consider their patients’ plans cally ill patient and make a rapid assessment and interof care in the context of all the factors that affect vention. According to the history taken in the ED, their lives. A woman in her 60s who has hypertension Nick was “Pale. Diaphoretic. Ill-appearing.” Nick had cannot afford the blood pressure pills that she must resisted going to the hospital earlier in the day, even take to avoid the risk of stroke and heart disease. though his headache was becoming progressively more “Should we prescribe a less expensive medication‘?” severe. The attending emergency physician and mediA 28-yr-old man has been in a car accident and has cal resident in the ED administered antibiotics and sustained minor bruises. His blood alcohol level at the performed a lumbar puncture. The working diagnosis time of the accident was 0.260. “How will we address was bacterial meningitis. his alcoholism?” A 4%yr-old man has been beaten up I:.-----RECEIVED : 6 December 1996; FINAL SUBMISSION RECEIVED : 27 August 1996; ACCEPTED : 19 September 1996