I am a family medicine physician well trained in Evidence Based Medicine. But sometimes I have a difficult case and my right brain takes over: TA DA! Fuzzy Poet Doctor, FPD, to the rescue. FPD is able to distract the logical left brain, knock it out and come to the patient's rescue.
This is currently my weirdest case and I have permission to write about it.
I was nearly done seeing Mrs. L and had my hand on the doorknob. Mrs L has diabetes and hypertension and heart failure and is a bit depressed and we were already over time. "Oh, by the way," she said.
I did not rip the door handle off. "Yes?" I said, hoping it wasn't chest pain. Chest pain would take another 30 minutes minimum.
"I have this friend in Arizona," she said. "She's dying. No one can figure out why. She is going to fly up here with her kids so that I can adopt them if she dies. Her ex-husband is abusive, and he can't have them."
"And?" I said.
"I told her she should see you." she said proudly.
"No." I said, "I'm just a rural small town family doctor and why would I be able to do anything different?" I was not happy. I promptly forgot it.
So her friend S gets off the plane with her three children and is hospitalized within 24 hours. Guess who happens to be the "star" doc. That is, the doctor to receive patients who do not have a local doctor.
I do not know that this is Mrs. L's friend. S is hospitalized for a high INR, concern that she might bleed to death. She had a blood clot in her leg back in Arizona and they put her on coumadin. Coumadin keeps the blood clot from getting bigger and from breaking pieces off that would plug up her lungs and kill her. That is called a pulmonary embolus.
She is in her early 50s and looks spectacularly awful. She looks starved from the waist up and edematous from the waist down. Edema is swelling and she has 4+, that is, the worst score. I can poke her leg and leave a 2 cm deep indentation. She is resigned to being in the hospital and to answering all the same stupid questions as in Arizona.
She has had a hip fracture recently, weird in a 50 year old. She was in a nursing home for a while. She has children and is divorced from an abusive spouse (no, I still haven't figured it out). She has hepatitis B and she has had her gallbladder out and she had surgery for morbid obesity, a stomach bypass, 20 years ago. She is postmenopausal.
In addition to a really screamingly high coumadin level (INR over 8), she has the lowest albumin that I've seen in a live person. 1.8. That is why she has the swelling. Albumin is protein made by the liver and if the albumin gets too low, fluid leaks out of the blood vessels in to the tissues. Her liver is not producing albumin, which is hard to fix.
The reflex doctor thought is cancer. The first three diagnoses are cancer, cancer, cancer, where the cancer is stealing the nutrition and the body is starving. She has had a very thorough workup for cancer in Arizona. I call her oncologist. "I'm sure it's cancer but we can't find it. We've looked and looked." She'll fax me notes. S has had cat scans so recently that I can't see that repeating them will help.
I write orders. Is cancer stealing the nutrition or is her liver failing from hepatitis B or both? I am not very hopeful.
I return in the morning.
Her INR is corrected to the goal for someone with a clot.
I'm confused. I go back to my orders. Each order has an explanation except one: the vitamin K shot. I remember that my left brain objected, "Her liver doesn't work." and my right brain said, "Shhhh! It can't hurt." The emergency room doctor didn't give her a vitamin K shot because he assumed her liver wouldn't work. The liver makes the clotting proteins but vitamin K is necessary for certain ones, including those that coumadin affects.
I sit down. Her liver is not shot and she was vitamin K deficient. So this does not fit. If her liver is working, why isn't it making albumin? Something is weird.
I called Dr. R, at the Big Hospital in the Big City. He is a wonderful liver specialist. I describe the whole history. "What is it?" I said.
He laughs, delighted. "You're right, it isn't liver failure and it isn't cancer."
"????"
"It is the stomach bypass gone bad."
"After 20 years?"
"Yes. They did a surgery that we no longer do and it's gone bad. She is not absorbing any nutrition and is starving. Her liver is fine. She needs the stomach bypass reversed. Call Dr. T. It's a really rare case!"
"Holy moly." But that DOES explain it. If she is starving, than she would be low on vitamins too. Even if she takes them, they aren't being absorbed. The fractured hip is early osteoporosis because she was not absorbing vitamin D either.
I call Dr. T. He agrees. He has me call the chief resident. The Chief wants me to CT her head to pelvis to make sure it's not cancer. I talk to S who says, "No. I've had 6 CT scans." Good point and by now I have notes from the oncologist. We transfer S to the Big City Hospital where Dr. T looks her over. He can't do surgery with her current horrible nutritional status, so she is put in a nursing home for a month with intravenous feeding and then he reverses the surgery. She returns to our town, normal.
And the next time I see Mrs. L, she says smugly, "I knew you could help S."
I did not realize that S was her friend until that moment. I get prickly chills all over. S is now my patient and looks normal. No edema and normal albumin. And she was dying. Maybe Mrs. L is the witch, I don't know, but I sure am glad my right brain writes orders.