Prejudice Guang-Shing Cheng (bio) A physician's greatest fear is to miss a serious diagnosis that can result in a devasting outcome—an acute anterior myocardial infarction, a ruptured appendix, an early breast tumor. Nothing reminds us of our fallibility more than when a patient dies of a disease that we had dismissed or even failed to consider. Whether we miss the diagnosis for reasons of incompetence, fatigue, or lack of time, these are the patients who teach us medicine the hard way and mold our habits. Think of sepsis in a patient with a low white count and hypothermia. Double-check the post-procedure chest x-ray with a radiologist. Never ignore a new complaint of chest pain, even in a young person. For me, the lesson came in the form of a patient I'll call Mr. Rennet. I met him at the end of a year of subspecialty training in pulmonary-critical care medicine. An intern approached me one morning for a consult: a thirty-eight year old man, morbidly obese and diabetic, admitted to the hospital a week earlier for congestive heart failure, a condition that causes excess fluid to accumulate in the lungs and other parts of the body. He had been treated and was discharged the previous night, but he returned because he still had difficulty breathing. The team wanted to know whether his symptoms could be due to a pulmonary embolus, a blood clot that migrates from large leg veins to the arteries of the lungs. They couldn't rule out pulmonary embolism because his size had hampered the work-up. The intern said, apologetically, "I think it's still cardiac," but my attending wanted the consult. Later that afternoon, I went to see Mr. Rennet. A bare-chested man sat up in bed eating lunch, leaning a protuberant abdomen into the hospital tray. I introduced myself. A heavy-set older woman, his mother, sat next to him and related the story while he consumed meatloaf and mashed potatoes. A week ago he had the same symptoms: a hard time breathing while walking, and really swollen legs. He had gained forty pounds in a month. How much did he weigh? Around four-fifty. They got a lot of the fluid off by giving him the water pill, so they discharged him yesterday. He had no chest pain, no more leg swelling, but he could barely walk ten steps. He felt better the moment he got back into bed, and he felt good now. How much could he walk before he got sick? Not very far, to the mailbox and back. Was he always so heavy? Yes, but more so in the last few years. Did he work? No, never had a job, just stayed at home with the parents. To listen to his chest, I asked him to lean to one side, then the other. The odor of dirty socks and unwashed armpit emanated from the exposed bed-sheets. Lung and heart sounds were distant, indistinct. Palpating the overhang of abdominal flesh that rested on his thighs, I left marks in skin that looked like orange peel, a sign of edema, likely to be from chronic heart failure. His calves were ruddy but symmetric, nothing to suggest a blood clot. His mother observed me, perhaps for a clue of what I was thinking. I wondered how a mother could let her son get so fat. I told them that the problem was most likely his failing heart, not a blood clot to the lungs, and that I just needed to review the studies that had already been done. This was clearly a young man with heart disease, a direct consequence of being obese. I flipped through the chart, noting the abnormal echocardiogram, confirmed by an abnormal cardiac stress test. A caveat: these were technically poor studies because of his extreme body habitus. The cardiologists deferred the cardiac angiography because the catheterization table had a weight limit. Pulmonary embolism was considered, but he could not undergo the definitive CT scan because the table cannot hold more than 350 pounds. Lower extremity dopplers did not show a clot in his legs, but a repeat...
Read full abstract
Dec 23, 2009
Xinyuan Dou + 6
Open Access
