Fading Scars and Memories
This is why I usually look at the old chart before seeing a complicated patient.
He was really old, and he was sent from the nursing home because his hematocrit was 18% (he had lost more than half of his blood cells somehow). I was surprised at how cheerful and coherent he appeared. Pale, yes, but in no distress and complaining of nothing. He denied any black or bloody stools, and his abdomen was soft and nontender. His stool was a little bit dark, however, and it tested positive for occult blood. His heart rhythm was normal, and his vital signs were perfect.
"Do you know why you are on Coumadin?" I asked him.
"I have a St. Jude valve," he replied. "Dr. Famous put it in me in 1977."
I was impressed how sharp his mental status was at that age, and how well he was tolerating his profound anemia. "This must have been a really gradual loss of blood," I told him confidently, "or else you wouldn't be looking so good right about now. Do you have a doctor here? Have you been admitted to this hospital in the past couple of years?" I asked.
He looked puzzled. "No....."
"Well, I'll find a doctor to tank you back up and make sure you're OK."
I reviewed his medical record and learned that he had been admitted here just a month before for anemia and GI bleeding. "I guess he fooled me," I told my nurse. "He isn't as sharp as I thought." As I was about to discover, neither was I.
"Page Dr. Stonewall! Let's get this guy admitted!"
As I was presenting the case to our hospitalist, I was shocked and embarrassed to note on further review of the patient's discharge summary that he had undergone a partial hemicolectomy to remove an intestinal tumor. Just last month. I didn't remember seeing a scar on his belly though. Had I examined him without pulling up his shirt? I didn't think so, but I sure didn't remember any scars on him. Damn, was I having a 5 am stupidity attack? I hate those.
"Why don't you check and make sure he doesn't have a colostomy or something," my colleague said icily, twisting the sword before I had even fallen all the way onto it.
I went back in to re-examine him, pulling up his gown. Still no scars; whew...now I was relieved but still confused. I pulled down his diaper a bit more, and hidden in a poorly-turgored skin crease of the right lower quadrant was a superbly well-healed scar, faded to the point of near invisibility from his anemia. He'd had an inguinal hernia there that happened to coincide with the site of the tumor, so the incision paralleled the inguinal ligament, exactly corresponding to the Langer's skin tension lines. Beautifully done, I might add.
He was really old, and he was sent from the nursing home because his hematocrit was 18% (he had lost more than half of his blood cells somehow). I was surprised at how cheerful and coherent he appeared. Pale, yes, but in no distress and complaining of nothing. He denied any black or bloody stools, and his abdomen was soft and nontender. His stool was a little bit dark, however, and it tested positive for occult blood. His heart rhythm was normal, and his vital signs were perfect.
"Do you know why you are on Coumadin?" I asked him.
"I have a St. Jude valve," he replied. "Dr. Famous put it in me in 1977."
I was impressed how sharp his mental status was at that age, and how well he was tolerating his profound anemia. "This must have been a really gradual loss of blood," I told him confidently, "or else you wouldn't be looking so good right about now. Do you have a doctor here? Have you been admitted to this hospital in the past couple of years?" I asked.
He looked puzzled. "No....."
"Well, I'll find a doctor to tank you back up and make sure you're OK."
I reviewed his medical record and learned that he had been admitted here just a month before for anemia and GI bleeding. "I guess he fooled me," I told my nurse. "He isn't as sharp as I thought." As I was about to discover, neither was I.
"Page Dr. Stonewall! Let's get this guy admitted!"
As I was presenting the case to our hospitalist, I was shocked and embarrassed to note on further review of the patient's discharge summary that he had undergone a partial hemicolectomy to remove an intestinal tumor. Just last month. I didn't remember seeing a scar on his belly though. Had I examined him without pulling up his shirt? I didn't think so, but I sure didn't remember any scars on him. Damn, was I having a 5 am stupidity attack? I hate those.
"Why don't you check and make sure he doesn't have a colostomy or something," my colleague said icily, twisting the sword before I had even fallen all the way onto it.
I went back in to re-examine him, pulling up his gown. Still no scars; whew...now I was relieved but still confused. I pulled down his diaper a bit more, and hidden in a poorly-turgored skin crease of the right lower quadrant was a superbly well-healed scar, faded to the point of near invisibility from his anemia. He'd had an inguinal hernia there that happened to coincide with the site of the tumor, so the incision paralleled the inguinal ligament, exactly corresponding to the Langer's skin tension lines. Beautifully done, I might add.
posted by scalpel at 11:01 AM
1 Comments:
I just wanted to say, I have added you to my link list. If that is not ok please let me know. I really like your blog.
Cathy
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