I'm sorry I've been buried the last couple weeks, as I've just started my general medicine rotation. Today is my post-call day, which means I get to sleep in and then study all day long. The fire hydrant of information is cranked open full bore again, and the shelf exam for medicine is supposed to the hardest. There is an incredible amount to know, and only a limited amount of time to assimilate it.
Inpatient medicine is especially challenging. It's funny because most people's perception of medicine is from all the TV shows about medicine and you see doctors constantly fixing some patient's problem and then they get better. If I had to pick one thing to change about the fictitious practice of medicine it would be this idea that people ever have a single problem. The more realistic medicine patient would be someone over the age of 50 with at least 5 or 6 chronic problems, and just one (or two, or three) that has put them over the edge requiring hospitalization. It's not about solving the medical mystery of the one thing wrong with your patient, it's about first stabilizing people who are very ill and then figuring out why someone who already has half a dozen things wrong is suddenly getting worse.
Let's do some recaps of fake medicine versus real medicine for fun. Let's start with a good House patient (spoilers abound):
TV Patient #1 - House: From last week's episode living the dream House kidnaps a soap-opera star because he determines something is wrong based on an imperceptible change in his "acting". Diagnosis? Quinine allergy. Patient is cured at end of episode.
Medicine Patient#1 (details scrubbed/jumbled of course): 68 year old female with COPD, A-fib, Type II DM, CHF and early-onset AD presents from nursing home with AMS (altered mental status). Diagnosis?
I'm sure PAL has already guessed a likely answer (or several dozen of them) - urinary tract infection. Granted, on the way we've performed a history and physical, gathered information, ordered tests, interpreted them, and honed in on an answer, but that's the basic story you get at first blush. It's pretty daunting. At the end, your patient isn't necessarily cured of all problems, but is hopefully returned to baseline. And critical to understanding how to treat the disease we must evaluate the whole patient. We don't treat altered mental status, that would be crazy. Instead we ask ourselves, in this patient, who is over 60 years old, in a nursing home, with multiple chronic diseases, difficult to interview due to Alzheimer's, and presenting with a change in mental status, what is the most likely answer?
One of the most common answers would be an infection, and common in this population is urinary tract infections, and a good physical exam as well as some rapidly performed lab tests targeted to this presentation should get you the answer. Based on a short differential diagnosis -DDx- would include stroke, MI, pulmonary embolism, drugs/intoxication, hypoglycemia/hyperglycemia, dehydration, bowel obstruction or infarcted bowel, trauma, depression, or sundowning, tests such as a complete blood count, basic chemistries, chest X-ray, electrocardiogram, troponins, PT/PTT/INR and urinalysis would likely have been ordered. That combined with an exam that would fail to support one of the other possibilities and we've narrowed down on a cause, treated it, and returned the patient to her old self.
TV Case #2 - Scrubs: My dumb luck A 40 something year old male patient presents with recurrent attacks of abdominal pain over years and poor doctor Cox doesn't know what to do. Diagnosis? After accidentally leaving the patient's urine in the sun JD and Turk realize it's acute intermittent porphyria.
Medicine Case #2: A 65 year old male former truck driver with COPD, A-fib, Type II DM, CHF CAD hypertension (starting to see a pattern?) presents to the hospital with Dyspnea.
This time I'll give you guys a chance at getting the answer. And give you an idea of what our workup looks like:
History of Present Illness (HPI): The patient is a morbidly obese male with a 50 pack-year smoking history, and a long term history of type II diabetes, hyperlipidemia and hypertension who at age 59 suffered a heart attack resulting in a diminished ejection fraction (35%) and exercise capacity. He developed COPD requiring home oxygen at a rate of 2L by nasal cannula about 2 years ago and as a result has quit smoking. Patient was at home with his family and after a big dinner of Virginia ham and a few bags of potato chips he began to have difficulty breathing. Patient denies chest pain, or palpitations. The patient's diabetes has been well controlled with metformin and injections of lantus and sliding scale insulin. His hypertension has been fairly well controlled by Lasix and Diovan
PMH: MI @59, DMII, HTN, Hyperlipidemia, A-Fib, COPD, CHF, depression
PSH: Appendectomy - childhood, quadruple coronary artery bypass grafting (CABG) @ 61, total knee arthroplasty @63.
MEDS: Lasix, Lantus, Insulin NPH, Zocor, prozac, coumadin, metformin, Diovan
Allergies: None known (NKDA)
Physical exam:
Vitals: Temp 37.5, Pulse 90, Resp: 28, BP 148/92, O2 93% on 10L nonrebreather mask, weight 352 lbs. Accucheck blood sugar 129 (high but ok), EKG - Right bundle branch block and q-wave changes present on previous ECG, increased signs of right ventricular hypertrophy
Gen:Obese man who appears older than stated age is sitting upright in ER bed, breathing with some difficulty on 10L nonrebreather mask.
Pulmonary: patient's lung sounds are bronchial, with bilateral wheezes and crackles.
Cardiac: no murmurs rubs or gallops, irregular rhythm.
Extremities: Edema 1+ in legs
The remaining physical exam is non-contributory.
So what do you guys think it is? What tests do you want to order? What do you think the treatment is? I'll tell you the results until I hear the right answer (PAL is allowed to ask for tests but no answers!). I actually gave you enough hints to make this pretty easy, just don't think too hard about it.
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As a entomology grad student, I've had to tell my family on numerous occasions if it doesn't have an exoskeleton, I can't help them.
That being said...all i can think of is bacterial pneumonia.
What's his temp?
What are the CBC results?
Katie, not a bad guess, would you like a test to diagnose that condition?
SES - pt is afebrile sorry, I was looking at the vitals thinking I was missing something.
CBC - White count 13 (mildly elevated), hemoglobin 14.6, hematocrit 40.7 plts 275
Because you'd get it eventually here are chemistries:
Na 129, K 5.3 Cl 95, CO2 23, BUN 24, Cr 1.3 and glucose 169
You can also ask for additional history if you have specific questions.
see anything on CXR?
CXR shows some pulmonary edema with diffuse white patchiness in both lung fields. The heart is large. PTX can be ruled out. You call the radiologists and they say it doesn't look like pneumonia but the diagnostic utility of the ER PA shot is limited by the patient's body habitus.
What you describe in your post is, of course, why I went into surgery instead of medicine. ;-)
IANAD. (Am epidemiologist and I used to be a direct-care nurse but have been out of the field for so long I have to look up lab ref values.) I want to play, though.
He's on Lasix but his K is okay, actually a little high, and his kidneys seem okay, so he's got some wiggle room to diurese if needed, right? Is that elevated BP consistent with his usual control? He sounds like he's working up a little CHF maybe - the side of the pump I'd expect to back up first is the right side, because that's where his past damage is, and he's here because he's not breathing right and his lungs are wetting up, so I'd want to at least consider whether he's in need of a little diuresis and some conversation about dietary sodium. If I were a doctor. Which I'm not.
So, is the irregularity in his heart rhythm old or new, and what's its character?
His heart rhythym is irregularly irregular, is old, that is his A-Fib, there is new some new suggestion of right ventricular hypertrophy by ECG.
I like where Jen is going, any confirmatory tests? Anything else you want to rule out? Any blood work we're missing? Or are we going to diurese him?
Is it heartburn or gas or something like that?
I mean a "big Virginia ham dinner and a couple of bags of potato chips"? Sheesh, that would make it hard for me to breathe with all that food smashing my lungs up to my throat.
You know, being a secretary and all, I'm SO qualified to even play the game. LOL
You question the patient about heartburn, and the patient says "oh, I also take rolaids for my heartburn, but this doesn't feel the same, I feel burning in my chest when I get that".
Heartburn can exacerbate some lung conditions, and reflux is associated with aspiration pneumonia.
echo?
PE maybe? Clot from Afib thrown into lungs and causing right heart EKG readings?
Oh, duh, he had CHF already in his problem list, too. I have no idea how to test for a CHF exacerbation - further visualization of the chest, like a cardiac echo or a chest CT? Do we already know as much as we're going to get from those, from the CXR?
I wonder, though, given this entry's multifactorial focus (I know that's cheating) whether there's something treatable driving the CHF exacerbation. He's got COPD, no surprise, and he's obese. I'm not inclined to think viral pneumonia because this was a fairly abrupt onset and he doesn't complain of feeling sick other than not being able to breathe. So I'm thinking he might well have an aspiration pneumonia, especially since he's obese so he might have some problems with a partly obstructed airway when he sleeps. (Does he drink at all? I assume his liver wasn't funky because you said it was non-contributory on the ROS, but it'd be nice to know.)
Uh, I don't know how to test for aspiration pneumonia, either. Chest CT?
By now, Marcus Welby (MD) would have diagnosed a green-apple belly-ache. ;)
Sounds like pulmonary edema secondary to right-sided heart failure to me - but what do I know? I'm a dentist.
I'd order three sets of cardiac enzymes, check his PT-INR because he takes coumadin at home, and do a 2D echo. But I'd probably go ahead and give 20mg of Lasix IVP and see what that does. Kind of sounds like good old CHF exacerbation.
Clearly he suffers from idiopathic post-prandial shortness of breath syndrome and should be put on anti-IPSOB medication. Easy.
I'd have to say, after seeing the results of all of the above tests...
"Go see a real doctor! I'm a computer geek!"
I'm remembering something about difficulty breathing combined with edema in the legs (that's just swelling, right?) Blood clots breaking loose? (That's my WAG, right there.)
This is a rather fun post...we may have to do this more often...
Pulmonary embolus? I ask because I'm a CT tech, and we get CT pulmonary angiograms ordered on these patients all the time. They can't lie flat or hold their breath and the scans are suboptimal. At least his renal function isn't too awful.
I'm going to take my own WAG. I'm not even close to being an MD. You said he just ate a bunch of ham, and a couple of bags of potato chips. That should elevate his Na and Cl, but they're below normal. I'm thinking of checking for an upper GI obstruction preventing food from moving into the small intestine, causing a distended stomach and pressure on the internal organs?
I can't diagnose the patient. I use to be an epidemiologist, but that was plant epidemiology. So unless he's suffering from powdery mildew or yellow rust, I can't help.
But I can diagnose the medical profession with an excess of gobbledygook.
Horses are more likely but zebras are more fun. Did a repeat and better quality CXR reveal anything new--perhaps evidence of pneumomediastinum? Was he drinking alcohol while eating his lovely meal of ham and chips?
DD:
1. Pulmonary embolism
2. Hypersensitivity reaction
3. Foreign body aspiration
4. Acute exacerbation of COPD
5. Silent MI
Investigations:
1. ABG
2. Spiral CT
3. serum tryptase
4. cardiac enzymes
5. ?bronchoscopy
bronchitis?
Also, I think the nurses in the N/H in your first case probably knew the pt had UTI - (smell and dipstick test as well as pyrexia)
I like this game. More please?
Di
37.5 is apyrexial? ok, forget the bronchitis then.
the haematocrit is low, the pt is wet, but the K and Creatinine are on the high side. If he wasn't so wet, the K + Cr would be higher, so I'll take a stab at pulmonary oedema resulting from developing kidney failure.
kidney failure is consistent with the history of diabetes and smoking.
What does his urine show?
What is his blood albumen?
When you ordered the cbc, did you get a bnp too?
Since I'm not going to get to hang around to here the outcome, I'll get way ahead of myself here and guess CHF. The salty ham and the potato chips are probably contributing factors and with an EF of < 45%, CHF would be either my first guess or, at least, close to the top of the list. Give the dude a big honkin' shot of lasix.
~I hate when I do that.
"Since I'm not going to get to hang around to here the outcome" should read:
Since I'm not goint to get to hang around here to hear the outcome.
Any complaints of cold extremities? (Leaning to worsening of CHF, or kidney issues)
The diagnosis is far beyond the wits of a left-handed, one-eyed musician like me. But, really, we need closure. What was it?
The diagnosis is far beyond the wits of a left-handed, one-eyed musician like me. But, really, we need closure. What was it?
Posted by: Scott | May 14, 2008 1:58 PM
Seconded. Mark, you're killing us!
Yes, I have refreshed many, many times.
so sorry. i'm back on call again.
The answer is acute CHF/COPD exacerbation due to excess salt intake. The serum sodium is paradoxically low because CHFers have dumb kidneys.
A doctor? On call? Likely story....
But seriously, what is meant by "dumb kidneys?" What do they do that normal kidneys don't? On the surface, it would seem that you mean that they filter salt out of the bloodstream quickly, but to my non-medical brain, that would seem like a good thing with a CHF patient.
The kidneys are frighteningly complicated, but a few different things are going on...to oversimplify...
When you're in heart failure, you are "fluid overloaded" and "dehydrated" at the same time...you have lots of water but in all the wrong places.
The kidneys and other organs detect the decreased effective BP of heart failure and compensate by trying to hold on to water and salt in order to "fill the tank", but water is somewhat more effectively retained, and you end up holding on to more water than salt, leading to low sodium.
Clear?
Wow. You all have more acronyms than the US military! I had to dump my brain of them after I was discharged just to free up some disk space.
Seriously, this is a real eye opener for just how involved the medical field is. I know a few people who "don't trust doctors", and I have to say there's no way they or I could attept to do it ourselves.
BTW always ask about acronyms...it's too easy to slide into them.
Clear enough for our purposes, thanks. I'm sure the details are beyond the scope of this forum.
This was a great post (+comments) to read.
So, do we get another one to play with?
I'll see what i can dig up for you