*takes a deep breath and gets ready to start*
*my pen drops*
*minor dilemma of ignoring or retrieving*
*picks up pen, takes another deep breath. jacket tumbles across crossed legs in a heap*
"screw it" i thought, exasperated. i took a deep breath and started...
i saw mr. m, a 50yo rock band manager who presented 24 hours ago with a 2-week history of abdominal distention and later, abdominal pain and diarrhea.
he first noticed his abdomen gradually swelling up 2 weeks ago, up to the point where he felt he had fat flanks. there was associated vomitting, 1x/day for the first 3 days of abdo distention that ceased by the 4th day. no blood was in the vomitus, no associated nausea but he lost his appetite.
about 5 days to a week later, he experienced pain and diarrhea. the pain was described as a band across his umbilicus, going across his abdomen. it was constant, dull with periods of exacerbations ranging from 2 to 7 on a pain scale of 10. no radiation of pain reported. lying/standing was more comfortable than being in a sitting position. the onset of diarrhea coincided with his abdominal pain. there was no blood or mucus in his stool, no pain on passage. he found it hard to quantify daily frequency but reported that he'd go 3 - 4x/day on his best days and every half hour on his worst, such as this tuesday post-CT. he has opened his bowels everyday although this morning was the first time he's passed formed stools. they were still semi-solid yesterday. his urine has been dark since tues, post-CT and has otherwise been normal in color and appearance. no pain on voiding.
he has been afebrile throughout the course of his complaints.
although he was unable to quantify his weight loss, he reported that friends have commented on him losing weight in the past few weeks. (i forgot to mention that until later on when they started asking for differentials. they got confused when i mentioned cancer mets. oops. i also forgot to mention: he hasn't done any recent travel to foreign countries and is unable to determine if he's come in contact with anyone suffering from diarrheal disease due to the vast number of people he meets as part of his job.)
mr m has been a smoker of 20 - 25/day for the past 35 years. he drinks 7 - 8 standard drinks of wine/day, reporting that he's increased intake to this amount over the past 8 years after his 2nd wife left him. his etoh withdrawal scale score was 13 upon admission yesterday morning but he scored 5 this morning.
he reports no history of liver disease, bowel disease, diabetes, cancer.
past surgical history includes an appendicectomy when he was 7 and a left forearm bone graft more than 30 years ago due to a mva.
relevant family history include, on his paternal side: lung cancer. his grandfather passed away from it at age 97, his father at age 83. on his maternal side, the only family history present was his mother dying instantaneously from a cva at age 54.
other medical history of mr m: he's been suffering from depression for the past 8 years but was only diagnosed 2 years ago.
he's on paxtine for his depression at home. in the hospital, he's on esomeprazole, timentin, morphine, maxalon, clexans + teds as dvt prophylaxis
when i saw him. mr m was alert, comfortably lying in bed watching tv. he had fluid drained from his abdomen yesterday afternoon and reports the fluid being "like urine" and becoming bright orange at the end of the tap. he's also had a CT on tuesday as suggested by his gp. he currently rates his pain as being 1/10.
on examination, mr m was a thin looking man, slightly jaundiced and was hooked up to IV saline + glucose. his obs were mostly stable... BP was 116/86, he was slightly tachycardic with a pulse of 105. oxyge- ...
"tell me about his abdomen" doc bisits interrupts.
*amy stares back blankly and prepares herself to wing it* you see, i ran out of time to write everything up so i had to go by my very rough scribbles and concoct a plausible tale.
<-- that. that was all i had to go by in terms of reporting about physical exam. i babbled about peripheral stigmata of liver disease and got cut off again! that was it.. i was getting a tad annoyed now. where is this going?? i'm wondering...
and then the viva portion started. tell me about signs of liver disease. what do you think is wrong with him. how do you explain his diarrhea. do you think he has cancer? what kind? how would you manage this guy as your patient if you knew that he's got ascites, bowel cancer and liver mets? what's his prognosis. and on and on it went for the next 20 minutes.
seniors and interns tell us to start with the basics if one's in doubt. when asked how i'd manage the guy, i started with the basics. said i'd get him to lay off the alcohol and the ciggies. that greatly amused my examiners, eliciting huge guffaws. urm... yay?
can't remember the rest of the viva.. it was pretty much all over the place. as disorganized as my initial presentation anyway. bottom line is that it's over =)
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