Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, March 13, 2005
    A Learning Experience

    I've been rounding in the hospital for the past week (hence the lack of posts). Our hospitalist quit a few weeks ago, forcing The Firm to jerry-rig yet another system for taking care of patients. The good new is that our senior managed care patients have been taken out of the equation and are being covered by a different hospital group. This means that we now have three different hospitalist groups taking care of different sets of patients (1: Commercial managed care, a.k.a. The Employed; 2: Senior managed care plans; 3: Fee-for-service/PPO/Medicare). It's all quite Byzantine, but considering that we're now covering for thirty primary care doctors it's good to split the load three ways instead of two.

    My rusty inpatient skills are improving. Yesterday I got a crash course in ischemic colitis. I had admitted a woman on Saturday who was complaining of severe abdominal pain and vomiting; CT scan showed no mass or obstruction. She'd had the same symptoms in January '04; the CT done then was likewise negative. What was seen, which I found interesting, was extensive vascular calcifications on the abdominal blood vessels. This woman is a known vasculopath, who's had both legs amputated below the knee. Could this be mesenteric ischemia? I called up two specialists to get some input. Their answer: a unanimous No. The vomiting was atypical (pain yes; blood yes; emesis no).

    I questioned the patient further. Suddenly, she started to complain vociferously about her grandson's wife (the patient is legally blind and the grandson and spouse live with her and take care of her). Diagnosis: stress? Possibly. She'd gotten much better overnight. I felt sorry for her, but solving a home situation problem is up to the patient's primary care doctor, not me. I voicemailed her regular doctor with the information.

    Several hours later I found myself admitting a 93-year-old woman who came in with the complaint of severe constipation, followed by explosive diarrhea, followed by blood in the stool. I phoned our gastroenterologist with the clinical info to see if he wanted to plan a colonoscopy for the next day. His immediate response:

    "This is ischemic colitis."

    "So I was wrong on the first one and missed the second one?" I replied. "Great."

    Give the guy credit, he laughed and kindly went through the symptoms of ichemic colitis with me and, more important, explained what causes them. The colon lining swells when its blood supply drops, blocking the passage of bowel contents. Then when the tissue shrinks down again, the pent up, pressurized contents are released with predictable results (all over the bathroom floor, in this case). The ischemic, traumatized tissue then bleeds, though usually not a lot.

    "Well, I learned something today. Thanks." With luck, I'll remember this next time I see somebody with abdominal pain and puzzling symptoms.



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