Friday, September 26, 2008

A Referral

I referred a patient to my alma mater today.
And I have to say, it felt a bit weird. To be calling WFMC, to be faxing in the paperwork TO them, instead of WITH them.
It was a case of Cushing Syndrome. Always difficult, these cases, because lab results are often equivocal, and often contradictory. Case in mind, guy who previously had a normal 24 hour urine free cortisol. I did a 1 mg dexamethasone suppression test which was negative, yet close enough to being positive that it just didn't smell right. And so I repeated the urine studies which this time came back positive. And did a salivary cortisol, further confirmed by the 2-day low dose dexamethasone suppression test I did, with a nonsuppressed ACTH.
His MRI showed a pituitary microadenoma. Presumptive diagnosis: Cushing Disease. Personally, I was confident enough of the diagnosis that I didn't think an IPSS (inferior petrosal sinus sampling) was necessary. But the neurosurgeon wanted that, and it's not something we have readily available here.
So, he's headed up to see if they feel he needs the IPSS, or if they are willing to operate on him based on the data I've collected thus far.
It's a strange feeling sending the patient up. In a way, it's pride, telling the patient that if I was going to have pituitary surgery, it would be by one of WFMC's neurosurgeons' hands. And another, that near-gleeful feeling, reminiscing and telling the patient how the system there works, and the qwerks of some of the consultants there and helping choose a consultant and surgeon for them, based on what the patient wants. And yet, mild anxiety, sending a patient to your ex-mentors and teachers, not as a fellow of theirs anymore, but as a colleague, hoping that when they read your referral letter and see your patient, they go
"Ah, Dr. Vagus did a good job working him up. We taught him well."
And not
"What on God's green earth was that idiot doing?? This patient doesn't have Cushings!!"
I think they taught me well.
I hope.
We shall see when after they are done with their evaluation.


Anonymous Anonymous said...

On behalf of many other Cushings patients, thank you for taking the professional risk of making this referral. So many of us have to fight hard, switch doctors, and travel across the country to get a diagnosis -- and quite frankly, Cushings just isn't as hard to diagnose as it was ten years ago. There are many new good tests, such as midnight serum cortisols and midnight serums to help gain clarity on the question.

The referral is clearly called for under the consensus statment for the diagnosis of cushings-- if your colleagues give you grief, give them some grief back. and then refer your patient on to someone who is more willing to consider the diagnosis, such at the doctors at Swedish hospital in Seattle, or Dr. Friedman in LA.

Again, thanks and thanks again. We wish there were more doctors with your courage.

7:55 PM  
Anonymous Robin said...

Way to go! For many, many years my local doctors did not 1) test adequately and 2) did not "risk" their reputations with referrals to an endo or specialist. I suffered with Cushing's for way too long.

9:19 PM  
Anonymous Anonymous said...

I think you should this case up.

5:04 PM  
Anonymous Penyu said...

so how was it? was it Cushings ds?

1:08 AM  
Blogger vagus said...

probably is pituitary in nature. but we'll have to see what the IPSS shows.
(inferior petrosal sinus sampling)

7:48 AM  

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