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.
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)
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.