Now this fits my definition of a great case – Cough, 102-Degree Fever, Lightheadedness

A few tidbits – then go read:

”She’s been like this for two weeks,” the mother began when the young physician entered the room. ”And no one can figure out why.” Her 21-year-old daughter had always been very healthy. She’d recently returned from a school trip to Africa, and she was fine throughout her month abroad. Even back at school she felt well until two Sundays ago, when she began to feel hot and sweaty. Just standing up made her lightheaded. A lengthy nap brought some relief but by the next day, she realized that she was feverish, so she went to the infirmary.

”I told them I thought it might be malaria,” the patient added softly. ”The teacher told us it was common where we were in Tanzania.” The infirmary nurse thought it was probably a flu. They’d seen several cases in the past few weeks at the college. But when the young woman didn’t get better over the next several days, a nurse referred her to an infectious-disease specialist in town. Maybe it was malaria. Since she had been in an area rife with this mosquito-borne illness, the specialist started her on a week of quinine and doxycycline to treat a likely case of malaria.

She took a full seven-day course, but the medicine didn’t help. Over the next few days she developed a cough so violent it made her vomit. She had abdominal pain that made even standing difficult. And she had terrible diarrhea. When she made yet another trip to the infirmary, they called an ambulance to take her to a hospital nearby. There she was given fluids, and blood was drawn and sent for tests. They told the patient she had mono. At that point, she was too sick to return to school, and her mother took her home to recover.

The internist knew that he needed help. He sought consultants until he made the correct diagnosis.

…I called Dr. Hammami with the news of the final diagnosis and asked why it had been missed by all the doctors the patient saw before arriving at his hospital. He thought for a moment before he answered. ”It’s difficult for a doctor to say, ‘I don’t know,”’ he said. ”The patient doesn’t want to hear it, and the doctor doesn’t want to say it. But in medicine you can’t know everything; you just have to know how to get the answer. I was certain the eosinophils would get us there.”

So go read the story and try to figure it out (I actually had the correct diagnosis very high in my differential). And applaud the internist for taking the time to think. Thinking takes time; insurers are loathe to pay for thinking; getting it right is more important than worrying about reimbursement.

Related posts:

1. On being a general internist, time is of the essence
2. What makes a high quality internist?
3. I am an internist – I am proud
4. Why become an internist?
5. In which I present my ideas of what is an internist

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