Wednesday, February 20, 2008

Me and My Big Head

Being a physician is for the most part a humbling experience. You think you’ve figured out the key to helping a patient control her hypertension, and the next week she gets admitted to the hospital with a pressure of 230/110. You don’t even think of asking the sweet grandmother about substance use, and she has a stroke from smoking crack. You reassure a chronically complaining patient that her shortness of breath is nothing to worry about, then find out that her oxygen level is low enough to qualify her for home oxygen. I shouldn’t be using the second person; I did all of these things.

But every now and then, you—I—hit one out of the park and feel like a freakin’ genius.

The other day, another attending was supervising the medical residents in the outpatient office when she pulled me away from my own charts.

“You like Derm stuff,” she said. “Maybe you can figure this out.” It was a very young woman who had what the attending and the residents thought looked like bad psoriasis—but it had happened very quickly and in some unusual areas, including in the places where she’d irritated her legs by shaving them dry.

I swept into the room, which was now filled with several residents, a student, and the poor girl, who was sitting on the table clad only in a gown. A red, angry-looking, scaly rash was spread over her elbows, her wrists, her abdomen, her knees, and down her shins. In many places, the rash was in the form of small round patches.

“Mm-hmm.” I said. “Tell me: did you recently have strep throat?”

“Last month!” she said, her eyes widening. The residents literally gasped. “It was culture-proven,” one of the residents said.

“Yep, that’s it,” I said.

What?” they all asked.

Guttate psoriasis,” I tossed off casually. “Happens after a strep infection. What’s on the legs is the Koebner phenomenon.”

Now they think I’m The One.

I won’t tell them just yet about the guy I said could go home who went to the ER instead and ended up in the ICU, intubated, in a hypothyroid coma.

18 comments:

Orange said...

That is hot.

Snickollet said...

Wow, you are The One. Very impressive.

applevenusian said...

Damn, Neo! You're good.

Anonymous said...

Great stories - all of them. I was going to email to ask a running question -- when you were preg with Hellboy did you run? thru the entire pregnancy? curious - I have GD (just diagnosed), exercise helps but I am not a big "walker". Much more of a runner - but it just seems near impossible with the basket-ball belly. Your thoughts?

Dara said...

Where were you 4 weeks ago when I dragged myself to the docs with a raging URI, saw the resident, followed by the attending who ordered a chest x-ray to R/O pneumonia, but both failed to recognize my other complaints of urinary incontinence, somewhat painful urination and 105 degree fever off and on for weeks? No one bothered with blood work or a U/A, sent me home with assurances that it was viral. To complicate the situation, I had just given birth 6weeks prior and was adamant about breastfeeding, so I wasn't hounding anyone for antibiotics.

I finally had to return 2/15, after another week of rigors and malaise. This time the resident pounded on my kidneys and after I stopped screaming, determined that I was one sick puppy, dx pyelonephritis.

Two docs trotted in to tell me that I had to take Levaquin and HAD to stop breastfeeding during the course of antibiotics, to which I started balling like a baby. I begged them to call the birthing center and speak to someone who had more expertise in lactating sick women, which they did and a course of treatment was determined where I could continue to breast feed. After one STAT dose of IV antibiotics, I am on 875mg of Augmentin twice a day for 10 days.

I am feeling much better..not 100%, but MUCH better.

Anonymous said...

Wow, way to go!

Denise said...

Oooh, you're like House! Was the epiphany prompted by something said by one of your sexy, yet strangely co-dependent colleagues?

(I'm sure that show is medically impossible, but I love Hugh Laurie in it.)

Vic said...

Brilliant. Everone needs to hit one out of the park from time-to-time. Bask in the glory.

Anonymous said...

I'll send my husband, who will only come down with a disease if it's unusual, to you!

So...have you heard of eczema herpeticum, hmmm (unlike the crowd of medical professionals who insisted on pumping him full of antibiotics to ward off a viral infection - duh!).

Fiona

RB said...

The Koebner phenomenon. It gets them every time. And it's so very easy and distinctive.

Christina said...

Doctors.. they're just like us. Makeing well intentioned mistakes.
Amazing.

and as my eight year old daughter said.. " of course it was an accident Mom. Otherwise, it would be called an 'onpurpose'."

Anonymous said...

fun blog. I can relate. I too am a burned out physician. Am trying to rejuvenate my spirit by blogging. Look me up. www.backcounterbuffet.blogspot.com/ I am new to the blogging business but am surprised by how much I enjoy it. Love the guttate psoriasis story..
Look me up

Julia

Ozma said...

Now that I've developed a few ongoing medical conditions, I've pretty much figured out there's some luck involved there with whether or not your doctor will know what is wrong. But it's awesome when they do. Score!

Val said...

So this gives ME license to brag about one of my "saves": 5-mon old MinPin puppy, brought in for "lump on shoulder"...
Puppy is grey, weak, & shocky -- long story short, lump is a rapidly expanding hematoma = acute rodenticide intoxication!
[Happy ending after pharmacomania + copious doses of Vit K]

Anonymous said...

I'm a medical student and I read your blog mainly for running tips + Hellboy stories. However yesterday I got sweeped into a clinic room by a consultant who demanded to know what rash I would expect given that the patient had a recent strep throat. Guess you can learn useful stuff off blogs. Thanks for the tute!

jenC said...

I don't kid myself that I could or should be a doctor -- I write and edit for a living, which just means I need to know everything immediately. WebMD and me? We're BFFs. (Although I'm usually seeing someone else within about 3 minutes.)

I feel like Wonder Woman when my educated guesses are right. I have learned, though, that it's much more helpful to tell a man that he has a "fungal infection" in his very deep bellybutton cavity instead of a yeast infection. Because yeast infections are only for vajayjays.

I made him clean it out and keep it dry, then eat yogurt and call the doctor that Monday. By the time he got there he was on the mend, but he got confirmation that I was right. And the next time he asked me, I was right again...I just didn't have a remedy for him and he's still suffering from a bronchial infection (for which the dr. gave him two inhalers and tylenol with codeine...which seems like a lot).

All this to say that, on a much humbler level, I totally hear you. And I love doctors that pay attention.

judy said...

I tagged you. If you want to do it here is the link http://averyopenbook.blogspot.com/
If it's not your cup of tea, no problem...just ignore it.

Stacy said...

Good for you! And I'm sure that patient was so thankful. It is SO great to have an accurate diagnosis. I am coming to the end of four months with a chronic cough, and it took this long and seven doctors (two of them specialists!) to get the correct diagnosis of sinusitis. This after I spent six weeks on asthma meds and feeling freaked out thinking I had asthma. Turns out sinusitis is the number one cause of chronic cough. I wish all doctors knew this!! I almost feel like getting a bumper sticker or something. :-) I enjoy your blog, please keep writing!