You must be really good then if you're still in trianing...

As I mentioned in my last posting, I spent this entire month doing my Internal Medicine rotation. I have a short story to share about what happen during one of my patient encouters.
So my team (which I really really enjoyed working with) was on call. The day had been going slow so I decided to go through some questions and readings. All of a sudden I heard "BEEP" "BEEP" that was my pager going off. I instantaneously called back and the resident said "Anselm, we've an admission here. Wanna take it?" I was like "Sure, of course". With my long legs, I was in the ER within the next 2-3 mins, ready to get an History, do a Physical and discuss about the work up plan with the resident and go from there. As I arrived at the ER, the met the resident who told me that ... "so your pt is a 49y/o African American female who has Abdominal pain and was has been admitted at an Outside hospital twice in the last 2 months for thesame complain. I really don't have much on her, go see her and see what you come up with." I said sure and was gone.

So I met the pt, introduced myself and began to talk with her. She initally gives me a very scanty history in the sense that she didn't want to give me much about her past history regarding her abdominal pain. Rather she wanted to focus on the present episode. I told her that obviously there must be something wrong going on, since she's had this same quality of pain for a couple of yrs with the severity getting worse. I pulled a chair and sat right across from her as she laid in bed on her right side with hips flexed. I asked her to take me back to the first episode and walk her way from there to where we are today. I was interrupting at times of course to guide her towards waht I thought was pertinent. From the look on her face, I could infer that she couldn't believe that I wanted to spend all this time with her and listen to what has happened to date. Well, she was a descent historian and even kept some discharge summaries from the OSH with her. I collected them, quickly glanced through some and read some, copying what I thought was pertinent to her presentation ( I guess as a med student you have more time to go through stuff like this). She described her pain as starting from the Right upper and lower quadrants and radiating to the Left quadrants then to her entire lower back; the pain was sharp, throbbing and aching with a severity of 10/10. She had an extensive history and throughout our conversation, she didn't request for any pain medicine but prior to that, she was getting Dilaudid quite often and had just received Toradol IV prior to me entering her room. The Toradol must have been doing a fine job. So as I was getting ready to do my Physical Exam, a nurse came in and said there was a bed ready on one of the floors and she needed to be transported to her room where she'll be during her admission. I told her that I'll meet her in her room.

A couple a minutes later, I was in her room ready to do the Physical Exam (PE) and the Husband walked in. He was a little helpful as he was able to tell me some results of imaging done at outside hospitals. I proceeded to do the PE and when I got to the Abd (where the money is), her Abdomen was diffusely tender but moreso on the lateral aspects. Both flank regions were tender to palpation (with the patient retracting herself from my hands) but the Left was more than the Right. Her labs were remarkable for a microscopic hematuria for which she said she has had a history of that.

From my exam, I was convinced that the kidneys were involved (the impressive flank tenderness) plus hematuria. This would explain the back pain but what about the abdominal pain - maybe it was radiating to her abd especially given that the lateral aspects were more tender. I did some search and reading and came up with a theory of my own: Was it a possible case of - Loin pain humaturia Syndrome (LPHS)?
Briefly, LPHS, is when the glomerular basement membrane (in your kidney) is very thin such that the normal pressure from blood supplying (perfusing) your kidney causes micro damage and bleeding hence the Pain and blood in urine. Classic presentation is unilateral flank pain and blood in urine (either microscopic or frank blood in the urine).

Well, the resident was quite interested in the case and asked my to present it at the morning report the following day but she cautioned me that students do NOT usually present and she'll be on the podium with me in case I needed any assistance. Well I did and she was wonderful in chipping in here and there and it went great. My attending congratulated me after the presentation. More tests and imaging studies will be done to workup the possible etiology of her pain. Too bad I wasn't going to be there any longer to see how it turns our. Usually the LPHS is a diagnosis of exclusion and if the w/u came back negative for the suspects then it makes my theory more credible.

Well, so back to my patient. Later that night I stopped by her room and she asked if I was going to be her doctor the entire time while she was at hospital. "I'm a medical student that is, I'm still in training, your doctor will be doctor P. But I'll be following you and working together with Dr. P" I replied. She then stated "You must be really good then if you're still in training. I was talking with my husband about how you really cared about asking me all the questions. About how you wanted to know everything about my pain and what I've been taking for it. Usually other doctors are just like okay we'll give you pain medicine and then they get me out of the hospital but no one has ever showed that they really care about my pain as you did." At this point my heart was racing and she continued "so I was telling my husband that I think this time, they gonna find what's wrong with me because someone's acting like they really wanna get to the bottom of this pain." Then I gave my little reason of why I went to medicine "b/c I really like to do my best to help people feel better and if there's anything possible that I can, I will which is why I was going through all what I did earlier and I also appreciate you being open to willing to discuss your history with us because it'll help us take good care of you" and also added that "the doctors that I work with here all care too and we'll do our best to get to the bottom of it." Then she said "well if they all care like you then I'm glad because I just wanna get this pain away, it's been bothering me for too long now and all I do is just pop pain pills which don't really help me."

I wish I could see how this case ends. Just one of those things that really gets me thinking even as I drove on my way home from the hospital.

Thanks for reading/visiting. Will be sure to write sooner.