This one has a game 🙂 Can you guess the right answer?
Some mornings I stare at my phone, 8:59, and count the seconds until the day’s Immaculate Grid arrives. For baseball lovers, the game is incredibly addictive – nine squares with criteria listed at row and column headers. This morning’s first square? Someone who has played for both the Mets and Angels. Easy. Nolan Ryan.
A few Sundays ago, I was called into work two hours early. There were people everywhere. I had one room to see patients and after I assessed them, those less urgent had to go all the way back out to the waiting room. My first six patents were fairly straight forward, so it seemed. They all went home with minimal intervention and seemed happy with their visit. But one came back two weeks later and was found to have metastatic cancer.
6 patients
Patient One is exactly 60 years old. Overnight, she’d awakened with a numb left arm. She’d been sleeping on it and when she rolled to the other side, the numbness resolved. She called her doctor who suggested she get assessed in the ER. She’s fit, perfectly healthy, on no medications and has perfect vitals. “Could it be that you just slept on it? Has it ever happened before?”
“Yes, but I’m 60 now, and one of my close friends just had a stroke.”
I tell her that her risk is extremely low, and after a discussion, she’s reassured and agrees to follow up with her family doctor. I don’t blame her doctor for sending her—in fact, I’m impressed that her doctor was available to chat with her on the weekend.
Patient Two is a 32-year-old woman with a ten out of ten headache. She’s wearing sunglasses and comes to the ER twice a year for migraines. There’s nothing new about this headache—she just needs her usual medication cocktail (Maxeran and Toradol, by injection) and wants to get back to her bed as soon as possible. After examining her quickly, I agree with her plan and ask the nurse to get her medication so she can go home.
Patient Three is in her thirties and it takes me a little while to figure out why she’s here. She’s had two days of vaginal bleeding, and the blood appears darker than usual. She’s otherwise healthy, and her periods are irregular so the timing of this bleeding isn’t completely unexpected. She doesn’t feel weak, she’s in no pain or discomfort and the bleeding hasn’t been particularly heavy. “So what are you hoping that I can do for you today?” I say. It takes several more questions but eventually I figure out that she’s had cervical dysplasia (abnormal cell growth at the cervix) in the past and because of the pandemic, it’s been several years since her last Pap test. She has a family doctor and after telling her I haven’t even seen an endocervical brush (the tool used to take a cervical sample) in ten years, she agrees to call her family doctor and schedule an appointment.
Patient Four is interesting. She’s in her early sixties and tells me that four months earlier, she developed a generalized rash and then swelling in her face and neck. She’s seen many doctors and is on eleven medications, some for chronic conditions such as high blood pressure and menopausal symptoms and some (such as steroids) for this rash and swelling. When she hands me her latest medication—a diuretic—she can’t remember whether it was prescribed for high blood pressure or swelling. When I examine her, I find a puffy face, a hump at the back of her neck and thin arms and legs. This looks like Cushing’s syndrome, a condition caused by too much steroid medication. It’s hard for me to figure out whether or not this condition was pre-existing (caused by too much of the body’s steroid) or whether it was caused by weeks of prescribed high-dose steroids. But the timeline fits with her medication being the culprit. As with all of my patients, I’ve scoured her medical record before seeing her and satisfied that she’s been well-investigated, I ask her to hold the steroids, and I schedule a follow-up appointment with our internal medicine clinic.
Patient Five is mid-fifties and is either coming from work or on her way there. She’s a personal support worker (she holds another job as well) and is still in uniform. She tells me that she’s developed urinary frequency, pain on voiding, and bloody urine. “I had this three months ago and it went away with antibiotics,” she says. When I ask if she has any other medical problems, she says no, although I know she’s an insulin dependent diabetic because she’d been admitted for an acute kidney injury (due to diabetes) earlier in the year. The discharge summary noted that she’d been a diabetic for a decade but abruptly discontinued her medications a few years earlier. After two days of rehydration and insulin initiation, she’d been discharged home. I ask her if she can provide a urine sample, and when she tells me she already has, she asks how much longer this will take. The nurses are keen to clear patients so when I ask for her urine to be dipped as soon as possible, the results are posted within minutes. It’s strongly positive for white cells, blood and nitrites, suggesting a urinary tract infection. I write a five-day prescription for antibiotics (the first script I’ve written so far) and ask her to come back if it doesn’t resolve.
Patient Six is my third sixty-something woman of the day. Her presenting complaint is “allergic reaction.” It’s her third visit in three days for the same thing. She has a fine, pink rash all over her body, most-apparent on her back. On her first visit, she’d been given Benadryl. The following day, when things hadn’t improved, she’d been given steroids. On day three, nothing has changed. She’s healthy, on no other medication and other than the rash, she has no symptoms. As I’m scratching my head, she remembers that two days before the rash had appeared, she’d visited a walk-in clinic with a sore throat. “They told me it was probably viral but took a swab.”
“Is your throat still sore?”
“No.”
I whisk out of the room and check the provincial clinical records system. Her swab result is posted—strep throat. And the rash? Classic Scarlet Fever. At her two previous visits to the ER, she’d forgotten about the throat pain and the walk-in visit earlier in the week. I write a prescription for Penicillin and she’s discharged home.
SPOILER ALERT: SCROLL SLOWLY….
One of these patients will have the same complaint fourteen days later and spend a week in hospital with a new diagnosis of cancer. Fortunately, I find out because I’m the one who sees her again.
At the second visit, under presenting complaint, her chart lists “uti.” Patient Five had completed her course of antibiotics a week earlier and although her symptoms improved slightly, blood persisted in her urine. Between two jobs, she’d been too busy to seek medical attention but on the morning of her second visit, she’d vomited once and developed right-sided flank pain. There’s been no fever and no other complaints other than simply feeling generally unwell.
Because of one-sided flank pain, vomiting, and bloody urine, I order blood work and a CT scan, suspecting a kidney stone. Several hours later, her results are back. Her white count is 12.5, and her hemoglobin, which had been 122 during her stay a few months earlier, is down to 97. More concerning, however, are her creatinine (kidney function) and CT scan results. Her creatinine is over three times normal and her CT shows severe bilateral hydronephrosis (fluid around both kidneys) with a suspected underlying bladder lesion (that’s bleeding and partially blocking the flow of urine from her kidneys). During her admission, investigations including a biopsy would reveal a high-grade bladder cancer and before discharge she would require bilateral nephrostomy tubes (external drainage tubes around the kidneys to evacuate the urine that had been blocked by her tumor).
In medical school, I was taught to find common ground with patients, and for all of these patients, we found common ground together on their first visit. I was motivated to clear patients from the department, and most of them wanted to get out as quickly as possible. The overnight numbness was reassured that she’d just slept on her arm. The migraine was happy to get her shots and go home to her bed. Maybe the vaginal bleed wanted me to do a Pap test right then and there, but she understood that we didn’t have the equipment in the ER and assured me she’d follow up with her family doctor. The woman with Cushing’s syndrome was happy to discontinue her steroids in hopes that her swelling would subside. And because of technology, I was able to look up my last patient’s throat swab and make the diagnosis of Scarlet fever.
Sometimes though, common ground isn’t in the best interest of doctor or patient. My fifth patient seemed to be in a hurry and started by telling me that the last time she’d had this problem, antibiotics made it better. The nurses (and I) were keen to dip her urine quickly and confirm the presumptive diagnosis to help clear out the ER. But her triage note described blood clots in her urine and made no mention of frequency or dysuria. Her kidney function had improved somewhat at her visit months earlier, but hadn’t returned to normal, and she’d never had an ultrasound during that visit. At the very least I should have ensured close follow-up. Alternatively, I could have made a note of her and followed-up on her urine culture which would ultimately grow no bacteria.
Often when I reveal the answers on the Immaculate Grid, I wish I’d have paid better attention, or thought about things a different way. When I review these six cases I feel the same way. Five were fairly straight forward and although the sixth seemed so, in the end it wasn’t. And I know that I could have done a better job.
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I thought it was patient #3…
Great read as always Raj
Corky
Great read Raj, I went with the migraines…
Thx Dino!!!! Great hearing from you!!!