April 12th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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I recently wrote about some awkward moments that I’ve had with my patients over the years. However, I think that Shadowfax’s blog post may win the award for most distressing patient encounter.
A hospitalized, elderly man was very ill and had requested to be considered DNR (do not resuscitate). Many years prior he had had a defibrillator implanted so that his heart would be automatically shocked if it went into an abnormal rhythm. His family gathered around him as he died peacefully from old age coupled with infection. The defibrillator, however, correctly recognized an “abnormal heart rhythm” (i.e. a flat line) and continued to shock the deceased man’s heart at regular intervals, causing his chest to twitch in front of his pained family members. The hospital’s defibrillator magnet (the off-switch for the device) had been misplaced, and so physicians were left to call neighboring hospitals and cardiologists to try to shut the machine off.
In the process of trying to locate the magnet, the doctors had to identify the brand of the defibrillator – a Saint Jude device. As it happened, one of the doctors receiving the request for the magnet was Catholic, and recognized the grim irony of the situation.
Saint Jude is the patron saint of lost causes.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 11th, 2008 by Dr. Val Jones in Uncategorized
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Last year I had the opportunity to participate in a cooking contest to promote awareness of celiac disease. As it happens, I was paired up with Chef Rock (he went on to win the TV cooking show “Hell’s Kitchen” and is apparently enjoying himself now in Las Vegas). CNN anchor Heidi Collins was one of the judges, and although our dish didn’t win (it should have! Who can resist shrimp and grits in a creole sauce? Is coriander encrusted skate really superior to that? No, I’m not bitter. He he.)
This year’s cooking spree is TONIGHT and I’m really excited. I’ve been paired with a chef from Cafe Atlantico, one of my favorite restaurants in Washington, DC. Many thanks to the National Foundation for Celiac Awareness for organizing the event. It may be televised (on a channel with a really high number I think), so keep an eye out for Dr. Val and her desperate efforts to take home first prize for all the people out there suffering from gluten intolerance!
Not sure what celiac disease is? Most docs don’t know either – so check out my interview with world-renowned gastroenterologist, Dr. Brian Fennerty, for more information.
I’ll let you know if we win – of if we just have a really good time!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 10th, 2008 by Dr. Val Jones in True Stories
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I’ve been presenting cases of important diagnoses made simply by physical exam. A ganglion cyst, a foot ulcer, and a dissecting abdominal aortic aneurysm were all correctly identified with a basic physical exam. However, there are times when a physical exam may not be enough – and reliance on it alone can be quite misleading.
A middle aged man was referred to our sports rehabilitation clinic after undergoing an unsuccessful orthopedic surgical procedure. He had been lifting heavy weights at his gym for some time, and was complaining of weakness in his right arm. He eventually got an appointment with an orthopedic surgeon, who noted that his right biceps muscle was severely reduced in its bulk. Assuming he had ruptured his biceps tendon, he was scheduled for repair the next week.
The surgeon was baffled after opening the arm and exploring the anatomy – the biceps tendons were both perfectly in tact, though the muscle was indeed quite atrophic.
What he didn’t realize was that the man had not ruptured his tendon, but had severely impinged his musculocutaneous nerve where it travels through the coracobrachialis muscle. The heavy weight lifting had caused his coracobrachialis muscle to hypertrophy to a point where the nerve supplying the biceps muscle was actually crushed by the size of the muscle.
The man slowly regained nerve function and was fine so long as he didn’t lift heavy weights again. The only long term side effect that he suffered was a surgical scar on the inner side of his right arm.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 8th, 2008 by Dr. Val Jones in True Stories
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I was working in the ER late one night when I was asked to see an elderly woman with the chief complaint of “I almost fainted.” This complaint carries with it one of the broadest differential diagnoses known to man. What could be the cause of a near fainting episode in an elderly woman? It could be anything from dehydration, to an irregular heart beat, to anemia, to malnutrition, to a urinary tract infection or pneumonia. Pretty much anything could make one swoon when you come to think of it.
And so I met the lady, perched atop a stretcher in one of the ER bays. She was chipper and friendly with a shock of curly white hair. She was sitting up, conversing comfortably with no pain or any bodily complaints whatsoever. She was absolutely charming, taking the time to notice my own disheveled condition and inquiring as to when I’d had my last meal.
Her blood pressure was a little bit low, but she had no fever, or heart rate abnormalities. She was not over or underweight, she was well-groomed and alert. I really doubted that there was anything wrong with the woman, frankly, and was kind of assuming that she had stood up too quickly and had a vasovagal episode.
But out of habit I began my physical exam, from head to toe – methodically looking for abnormalities of the head, eyes, ears, nose, throat, cranial nerves, chest, lungs, back, skin, range of motion of arms, strength, sensation, heart sounds, and then the abdomen. As I placed my cold hand nonchalantly on her belly, my arm instinctively jerked away almost before my cerebral cortex was able to interpret the input. Oh my gosh, there was a pulsatile abdominal mass, clear as the nose on her face!
I was barely able to compose myself and asked her to excuse me. I bolted straight for the attending’s desk, and white as a sheet with wide eyes I stammered: “the lady in bed 3 has a pulsatile abdominal mass!”
The attending stood up immediately and followed me to the lady’s room and confirmed my diagnosis. She had a dissecting abdominal aortic aneurysm. We called the trauma surgery team and she was taken to the OR minutes later. The dear lady survived the surgery and was discharged home in her usual state of pleasantness. I’ll never forget that physical exam finding, and how taking the time to place my hand on her belly was all that was needed to save her life. If I had gone with my suspicion prior to the exam (that she was fine but maybe had a UTI) I may have wasted the precious few minutes she had (before her artery ruptured) on getting a urine sample!
***
For other surprising physical exam findings, check out part 1 and part 2.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
