Another Interesting Case

I saw this interesting case that has me salivating all over it. No it's not because she's hot; but rather like many academics out there, I'm pretty much a nerd and a sucker for interesting cases. I'm in the midst of working her up but I have a pretty strong hunch.

This was a 54 year old woman referred to me for 'hypothyroidism'. Was found to have an elevated TSH of 6.2 (normal 0.5-4.5). Her GP started her on Levothyroxine and was puzzled when her follow up labs yielded a TSH of 7.2 and a free T4 of 2.3 (normal 0.5-1.5). The labs remained about the same after the medications were subsequently stopped.

Her history is otherwise significant only for hyperlipidemia, mild hypertension and a history of hysterectomy for fibroids. Family history is negative for any thyroid issues though diabetes is somewhat prevalent in her family. Aside from some rare palpitations, she feels well.

How would you proceed working this patient up? What is your preliminary diagnosis?

Someone explain this to me:
Why do dogs like to stick their heads out of moving cars?

Consults I Dread Seeing

I'll be honest. I think I had pretty good medical training, and I consider myself to be pretty damn good treating certain conditions like thyroid nodules/cancer and pituitary problems. Having said that, there are some consults I really dislike seeing, often because of misinformation to the patient from the referring physician, or misguided expectations. In random order:

1. Weight gain- "It must be the thyroid because you can't lose weight. Never mind that your TSH/fT4 were normal"
2. Fatigue
3. Night sweats- I saw one of these patients yesterday- she was a nurse and was befuddled when her referring MD punted her to me. She actually asked him, "My thyroid labs are normal- why are you sending me to an endo?"
4. Hair loss- unless this was thyroid or hyperandrogenism in nature, please do not promise the patient I can help them grow their hair back. A dermatologist would be smarter then I am in that regard. Believe me if I could treat this I wouldn't be putting up with thinning hair myself
5. Adrenal fatigue- despite a robust AM cortisol, and/or a normal ACTH stimulation test. I don't want to start a debate since I know what the believers say, but the science says otherwise. And I consider myself a scientist.
6. Low libido
7. Mood swings- (are you kidding me? My WIFE gets these. Heck, I get these myself)
8. Decreased muscle strength- I see a few of these regularly, usually bodybuilder types who are already benchpressing >150 lbs and have biceps the size of sequioa tree, but still aren't happy they aren't getting stronger. Some of these eventually make it known that they are hoping for anabolic streroids
9. Wanting a bigger penis- no, I kid you not. Seen a couple. Nothing I could do, unfortunately
10. Syncope- this one probably wins the prize, and I've gotten a handful of these from, of all people, a cardiologist!

Not that I'm downplaying any symptoms, just that there are some things the science and medicine and research has shown to be hormonal in nature. Many others, however, are not, and when the GP promises a cure from me (I suspect it's usually a case of them not having the foggiest idea and so making a blanket statement of "it MUST be your hormones" without actually having found any abnormality), is often counter-productive to the patient and a waste of their time. I can't say it's a waste of my time because the patient ends up paying to see me, but I do wish I saw fewer of these, and more of the stuff I can actually help people with.

The Weekend That Was

We had a swell time. Never mind that the weekend was short.

Good friends, good food, lots of alcohol, and a firepit.

We rental a lodge in the Dells. It was a good 5-hour drive for Kristin and I, but armed with buckets of snacks and a 10-hour audio novel, the drive turned out to be pretty pleasant and not too tiring.

We met up with the gang in Wisconsin, dear friends from our alma mater, for a Malaysian-Singaporean reunion. It had been a while (since we moved to IA) since we had the company of our friends, with no regards for any curfew or needing to hold back on alcohol because we had to drive- basically we stuffed ourselves with food and wine/beer/mojitos (whenever we get together, we inevitably overeat. I came back 1.8 kgs heavier. Seriously).

Also spent the better part of a day hanging out at one of the indoor themeparks. I think the adults had as much fun as the kids with the laser tag, rock climbing and go-carts. I realized how much I missed my pals, and how precious these little gatherings are for us to catch up, be ourselves amongst our 'family' or just to see how much their kids have grown. Yes, we had fun, indeed.

And what better way to top this up than with a nice, toasty campfire to warm you on the outside, and lots of alcohol to warm you on the inside?
Thanks, guys, for a fun weekend!

Popquiz

Question:

What do you get when you stuff:

1) 10 adults

2) 9 kids

3) Lotsa food

4) Highly flammable stuff

... under one roof for the weekend?

Answer:

A weekend full of chaos and fun! Will be meeting up with good friends for a weekend getaway and some much needed R&R.

PS: If I'm not back by Monday, someone please come and bail us out from jail.

End of life

I was asked to to manage this patient's diabetes while he was in the ICU. As my medstudent presented the case to me, things began to sound grim.

This patient, a longtime diabetic on insulin, had a cardiac arrest shortly after a surgical procedure. Despite valiant efforts on the part of the code team, they had difficulties intubating him (congenital malformation of the airway) and then bringing a pulse back. Once they did, he was brought to the ICU. They coded him for over 10 mins, apparently. He was only 58.

Because things happened so fast, when he was apparently doing well, the family was left unprepared for all this. When I went in to examine the patient myself, they were optimistic, talking about how they were expecting him to wake up any day. The nurse, however, had told me that the neurologists had already given them the bad news and that the damage was done, but perhaps because of the shock, they had trouble comprehending the implications.

After I had requested for some private time to examine him with my medstudents, it became very clear to us. I opened his eyelids; his pupils were fully dilated, with no response to light.

When I was a medical resident, one of the things I hated most to do was to 'call' a patient. You check for signs of brainstem reflexes. Verify the absence of spontaneous breathing or a pulse. And then you say, as if to an audience, "Time of death ...".

Being a subspecialist, I tend to stay focused on the matter I've been consulted on, and steer clear of other issues. In this case, it was neither my duty nor my place to try to convince the family of how he was never coming back, and how he was being kept alive only by the ventilator. I don't miss those life-changing and devastating (for the family) discussions about the futility of keeping a patient on the vent. Nonetheless, it was a bit difficult to watch what that family was going through, and knowing what they would eventually go through when it sunk it.

And so, we came up with a reasonable insulin plan for him. And I quietly said a prayer for peace, for him and his family.

You know it's bad when...

... the radiologist gets the right side confused with the left.

It's a good thing I did an ultrasound of the neck before I stuck that needle in.

ALREADY???

A (medical) horror story

My wife shared this story with me the other day, of how a surgeon scrammed shortly after he was done with surgery just so he could start with another surgery on another patient, in another hospital.

Except he didn't wait till this patient was in recovery. And so, she started deconpensating; she started bleeding vaginally. Heavily. And the anesthesiologist tries calling the surgeon. Except he doesn't answer his pager.

Finally, after what seems to be an eternity, he calls back. And gruffly says that he is late, and doesn't want to bump the other case. Tells them to 'hold pressure'. He's not going to come back to this hospital. In other words, he doesn't want to cancel that other case to come back to deal with this. Read: It's going to cost him too much money in terms of OR time to cancel a case to come back to deal with this if this turns out to be a 'minor' problem.

And so the OR nurses and anesthesiologist are left with trying to stabilize a bleeding and potentially unstable patient for the next half hour. In the end, thing turned out OK. But the story gets us mad. Not that this is an exceptional case; I'm sure this happens in so many hospitals, because the truth is many doctors have privileges in multiple hospitals, something many may consider to be a mild conflict of interest. In this, my wife and I miss working at our alma mater. Yes, we're biased, but hell, I think for good reason. There's a good reason the WFMC is ranked the number 2 hospital in the country. The physicians and surgeons there simply are not out to make money- they're salaried and it doesn't matter if they rush to see more patients. And they see patients only in one medical center- they don't work in multiple systems.

And so, when people ask if I miss working in an academic institution, at the WFMC, deep in my heart, my answer seems clear. But I am here, and this is now, so it's pointless missing the past. All I can say is that I hope my loved ones are never under the care of a doctor like that.

Finally, they're getting it out. I'm glad the Star published this yesterday, which prompted a statement from the DG.

PETALING JAYA: There’s a scam going around and what they are after is your blood. With just a drop, unscrupulous doctors, sinsehs and alternative medicine practitioners claim they are able to diagnose a host of illnesses, ranging from vitamin deficiencies to cancer. They are able to convince their unsuspecting patients by using an impressive but discredited test method called Live Blood Analysis (LBA).
It is believed that thousands have fallen victim to this scam over the past 10 years. Alarmed by the growing number of centres offering such services, medical associations are now urging the authorities to take action against those offering LBA.

Medical doctors also criticise the test as a fraudulent practice to mislead unsuspecting people into buying unnecessary and expensive supplements or alternative therapies for non-existent medical conditions.
Malaysian Society of Haematology president Dr Ng Soo Chin said: “The society’s stand is very clear - LBA is junk science. It is a mixture of a little bit of science that is unsubstantiated and interpretations that are erroneous.

Perhaps with more public awareness maybe fewer people will fall victim to these scams. Not only are these scams costing patients a lot of money, but they may also taking them away from the care that these patients may need.