April 14th, 2008 by Dr. Val Jones in True Stories
Tags: Fitness, Humor, Personal, Weight Loss
4 Comments »
My husband has perfected the art of dry humor. He is very thin and naturally athletic and I tease him a lot because I’m not as thin or naturally athletic (ahem – yeah, I’m jealous). So we have a running joke about him being skinny.
Today I needed to find my sister’s mailing address really quickly, and realized that the only place we had saved it is my husband’s Gmail contacts list. To retrieve them I’d have to use his login and password (which I could guess at, but didn’t really want to do without his permission first). Unfortunately I couldn’t get through to him at work, so I just went ahead and logged in (correctly guessed his password) and retrieved my sister’s address.
I emailed my husband apologizing for hacking into his Gmail account without his permission. This was his response:
“That’s ok. I’m the only skeleton in my closet.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 13th, 2008 by Dr. Val Jones in True Stories
Tags: Cancer, Emergency Medicine, Neurology, Neurosurgery, Ophthalmology, Parenting, Pediatrics, Personal
5 Comments »
I received a panicked call from my younger sister today. She is the mother of one-year-old identical twin girls, born slightly prematurely. During her pregnancy she had a problem with twin-twin transfusion syndrome and had to lie on one side for many weeks to ensure that both girls received an adequate blood supply. She delivered by Cesarean section and fortunately both girls have been doing well. That is, until a few hours ago.
My sister described an episode in which her daughter was in the bathtub and suddenly had one of her pupils become very large. It remained dilated for several minutes, which caused her to call her husband in to take a look. He confirmed that the eye was dilated and they decided to call me right away because they’d heard that a dilated pupil might have something to do with concussions or head injuries, though the little girl had not had any recent trauma to her head.
I tried to get a full history from them – they said she was acting “totally normally” – the usual peeing, pooping, eating checks were fine. They said she was sleeping well, not vomiting or lethargic, and that her pupil had now (after several minutes) returned to normal size. They said her fontanel was not bulging, and when I asked them to shine a light in her eyes they both constricted immediately.
My sister asked me, “what could this be?”
Ugh. I’m not a pediatrician, nor an ophthalmologist, but I do know that asymmetric pupils are usually an ominous sign. All I could think of was “space occupying lesion” but I didn’t want to scare my sister unnecessarily. All the other history sounded so reassuring (the child was well, with no apparent behavior changes, the eye had returned to normal, etc.) that I had to say that they should get in touch with the pediatrician on-call.
And here’s where things got confusing. My mother called me by coincidence just after I hung up the phone with my sister. She had been visiting with the babies for a full week, and slept next to their cribs during their vacation. I told my mom about the pupil issue, and she started relaying some potential “symptoms” that she had witnessed over the past week or so. She claimed that the baby had indeed vomited recently, that her behavior was different than her twin (more irritable and emotionally labile) and that her sleep patterns were also disrupted.
Now I was more concerned – was this early hydrocephalus or maybe even brain cancer? Would I be responsible for missing a diagnosis? I was thousands of miles away from the infants and trying to piece together a story from historians with different observations. So I called some pediatrician friends of mine and asked what they made of this. One said – “anisocoria is a concerning symptom in an infant, she needs a CT or MRI to rule out a tumor pressing on her eye nerve. She should go to the ER immediately.” The other said that since there were no other current symptoms, and the eye was back to normal, it should be worked up by an ophthalmologist as an outpatient.
What a bind to be in – I have some witnesses describing very concerning symptoms, others suggesting that everything’s fine except for a fleeting period of pupil size mis-match. I have dear friends suggesting everything from an immediate ER visit with sedation of the child and a head CT or MRI to watchful waiting and distant outpatient follow up. And I have my sister relying on my judgment (as a non-pediatrician) to tell her what to do.
Here’s what I did – I got my sister and her husband on the phone and explained to them that I take their observation of pupillary dilatation very seriously. I explained that this is not a normal event, and should be followed up by an expert to make sure that there’s no underlying cause of the eye symptoms. I also said that the fact that the baby is acting normally and the eye is no longer dilated are reassuring observations. I told them that they should keep a close eye on the infant, and that if they see any hint of recurrence of the pupil problem, or anything out of the ordinary like vomiting, inconsolability, lethargy, swollen fontanel, fever, or strange body movements or seizures, they should go to the ER immediately. In the meantime they should alert the doctor on-call to the situation and discuss everything with their pediatrician during her next available office hours.
I hope that was the right approach. I will not rest easily until the baby has been fully examined by an expert. Being a doctor carries with it a lot of anxiety and personal responsibility – at any time of the day or night your peace of mind can be uprooted by an abnormal finding relayed to you by friend, family, or patient. And if anything goes wrong – or if interventions are not achieved at an optimal speed and accuracy, this question will forever plague you: “Should I have done something differently?”
Who knew that my relaxing Sunday afternoon would be turned upside down by a dilated pupil?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 10th, 2008 by Dr. Val Jones in True Stories
Tags: Fitness, Neurology, Orthopedic Surgery, Physical Medicine And Rehabilitation, Surgery
3 Comments »
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
Tags: Cardiology, Emergency, Geriatrics, Surgery
2 Comments »
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.
April 2nd, 2008 by Dr. Val Jones in True Stories
Tags: Finance, Hospitals, Medical Malpractice, News, Surgery
5 Comments »
I’m at a medical conference in Houston this week (picking up some CME credits) and between lectures I’ve had some interesting conversations with my peers. Here’s my favorite story:
A patient underwent a total hip replacement surgery, had a normal post-operative course, was transferred for inpatient rehabilitation, progressed well and was discharged home. Several months later the patient decided to sue the hospital, claiming that he was sent home with a dislocated hip. The hospital couldn’t prove that the patient’s hip was not dislocated at the time of discharge because no x-ray was taken on that day. Of course, the only reason an x-ray would have been taken was if there were a strong suspicion of a fracture or dislocation (x-rays are not normally repeated on the day of discharge).
The hospital was found liable and will settle out of court for an undisclosed (but very large) amount.
My guess is that this case will cause:
1. The hospital to take unnecessary x-rays of all total hip patients on the day of discharge from now to eternity.
2. More dishonest patients to file frivolous law suits.
3. The local med/mal attorney population to spread the word about a new source of income.
4. Further cutbacks in the hospital’s charitable care due to funding deficits.
5. Someone with a hip replacement to buy a new Ferrari.
Sigh.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
