Saturday, December 19, 2009

Case of SOBs

I'm finishing up my preclinical book work and heading to the clinics in a month and things are so much fun.  Now we've done all the organ systems and so when we get these case presentations to work on, it's much more like having an actual patient.

23 y/o (year old) male presents with SOB (shortness of breath), fever, and cough.

PE (physical exam): Febrile (fever), dyspnic (pain on breathing), tachypnic (having really tacky pnics)
ABG (arterial blood gas): 7.48/55/98/22

"Now what's the differential diagnosis"  This is the most fun part.  Everyone knows what this is.  Everyone has seen a medical show of some kind and this is the part where they start to list diseases, each of the students saying a disease in turn at a fast clip, followed quickly by the head attending agreeing or another resident going, "Yes, but it's an acute presentation.  We must be missing something" (because they are always missing something, usually something they can find in 22 minutes plus commercials). The attending tells them to do something procedural sounding, the word, "stat" gets thrown around, a montage of hustling and needles begins, it's pretty special.  This is not at all how our sessions go.

We stare blankly for a solid 20 minutes until an MD/PhD who has done extensive research on ARDS raises her hand and says something really brilliant like, "asthma?"
We all congratulate her, exchange some high fives and start to pack up..."but the fever and blood gas don't really indicate asthma".
Ok now we are in a bind.  21 young doctors in training have a fake SOB with a fever, and if we don't do something fast this patient is going to die.  Or live.  Or whatever has already been written out for him in the rest of the case that none of us have read ahead of time.  Then someone looks at the title of the workshop, "Pneumonia".
"Could it be Pneumonia?"
"Brilliant!"  The doctor says something else, but he is drowned out by the thunderous sound of high fives.  When they die down, he follows up, "Now what do we want to do for the patient?".  Aww shit, it's one of those patients.  Fine. 

I got this one.  Earlier today, I was texting and rudely interrupted by the lecturer turning the lights out so we could see a CXR(Chest X-Ray), I'm gonna go with the recency effect:
"Chest X-Ray?"

"Exactly!"  My hand becomes inflamed and erythematous (hurts) from the high fives.  So we get a Chest X-Ray. Put in the order, take the patient to radiology, set the patient up, help the tech out, get the films on disk, bring them back to the doctor.  See?  I watch medical shows too.  I actually have no fucking clue how you get a CXR.  For our cases we just turn the page and there is a picture of lobar pneumonia from our patient, who according to the picture records, was lying about his age since the CXR was taken in the 80s and suddenly has breast tissue.  And this is how cases go.  Did I mention that in a month I'm supposed to be doing this with real people?

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