From Prinzmetal's to Pneumonia: Comm Week #5

Boone saved its best week for last. I spent these past few days on my last mini-rotation out in Western, NC with my Pediatrician, using as much time as I could to "act like a third year." Unlike weeks prior, I saw each patient by myself, I presented the findings to my doc, and I came up with a short assessment and plan. I performed a full interview and focused physical exam, and (attempted) to come to my own conclusions. It is the closest I will get to actually being "on the wards" with an attending until July 1. It was fortuitous that my pediatrician had much of the week on call, so time was spent rounding on patients in the hospital in the mornings, then I saw "acute" care patients in the office that night. "Acute" is in quotes because technically "the sniffles" count as an acute condition. "The sniffles," however, have a wide variety of potential diagnoses: from a cold or the flu, to strep throat or pneumonia. I worked each of them up and moved on. I kept my presentations to 30 seconds or less, and got much more efficient as the days progressed.

For some patients, I knew exactly what was going on. I would look into an swollen, erythematous mouth, and it screamed strep throat. Pulling on the ears with fluid-filled, nasty looking tympanic membranes? Otitis. Seal-barking cough? Croup. I suggested we order a strep test, antibiotic, or breathing treatment. But other times I totally missed the ball. There were definitely ups and downs. From a medical standpoint, this week was by far the most interesting. I sat in on a Marfan syndrome consult, met my first patient with Turner syndrome, saw a kid with 5th disease, and worked on a differential for a 17 year old with chest pain.

And then other times I totally missed the ball.

The peak for me was on Thursday morning. The night before, a 17 year old girl came with her mother to the clinic, presenting with a progressive onset of crushing chest pain. About a year ago, she started have very short bouts of heart palpitations, sometimes accompanied by mild chest discomfort. At first she chalked the symptoms up to stress or coffee, since the episodes were rather infrequent. But steadily over the past few months, the pain had gotten worse and worse. She finally came into the clinic because now she was having trouble breathing. The pain had gotten so bad that she would have to lie down for an hour or so until the episode subsided. And now over the past month, these episodes became daily.  The pain was never associated with exercise, and it always occurred at night. The previous evening, the girl was given asthma medicine to see if helped, but to no avail. She met us in the office at 0900.

My pediatrician and I saw the patient together. He asked all the questions, and performed a full focused physical. Commonly, reflux or epigastric pain can mimic cardiac angina. However, her episodes never directly followed meals. Teenagers are also prone to swallowing pills without water... I still do it just to show I'm tough. Unfortunately, pills can lodge in the esophagus, causing ulcers that burn holes through the mucosa. Our patient was taking a medication, but she started well after the chest pain began. It was clear that she was going to see a pediatric cardiologist, since one visits the clinic every other week. The whole situation sounded familiar to me. Young female with crushing chest pain, always at night, not associated with exercise... honestly it sound like a multiple choice question I've heard. So I mustered up the courage to throw it out there. "Hey Doc, what about Prinzmetal's angina?  It is possible?  I was met with a smile. That could be a possibility.

I don't know. It was nothing big, but it was kind of cool to come up with something on my own that wasn't "ear infection" or "the flu."

Literally two patients later I totally missed pneumonia. The one physical exam technique that I've felt mildly competent with over the past year and a half has been auscultation of lungs. I think I can hear breath sounds pretty well, given that I've heard a ton of wheezing from asthma, and fluid-filled lungs in CHF patients through EMS. So I felt confident. And then next thing I know I'm telling a mother that her child's lungs sound clear to me (NB: I always finish up with, "But we'll let the real doctor make the call." I'm not that experienced, and I don't want parents thinking I'm their definitive diagnosis). My doc walks in and BOOM: those lungs on crackling and popping. Good thing I qualified my assessment, but I couldn't have instilled much confidence when I quickly reported in my presentation that the lungs were "clear to auscultation."

Oh, how quickly the mighty fall.

So I'm a ways out before being any good. I'm not ready, but I'm getting there. It's good experience, although I think that next year is going to be a shock to the system. Well oh well, on to Spring Break! Too bad I won't be in Peru this year :(

Goodbye, Boone!