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The one that got away
By James S. Newman, MD, FACP
I grew up in scenic Brooklyn, New York. Needless to say, there were not a lot of opportunities to go fishing, except at the periodically stocked, stagnant lake in Prospect Park, where you could stand between piles of food wrappers and other biologic detritus and enjoy a few idyllic casts before your cheap reel ended up a tangled mess. I was more “Go Fish” than “go fishing.”
I've known a few ardent anglers and half-crazed casters, each more obsessed than the next. I had a friend who was a genius trout fisherman, and another who reveled in trespassing to find the perfect fishing spot. Even now my friend Dan is always trying to coax, shame or dare me into a piscatorial pursuit, never succeeding. When we lived in Galveston, Texas, I do admit to occasional forays into my backyard on Lake Madeline. We had an old crab cage we would fill with leftovers and dump into the saltwater lake. A day or two later we'd pull out the cage to find a few crabs, and an occasional suicidal shad.
Photo courtesy of James S. Newman.
Last month I was on the residents' service. They generally try to keep me away from impressionable youth, but I guess nobody else wanted to work the holidays. The admissions were not coming hot and heavy—more cool and light on this snowy December day. Our last admission of the shift was a patient with anemia.
Our medical student began to present the case. Somehow, he stayed on target despite my tangential questions, odd historic references, running commentary, constant interruptions and fidgeting legs. The bottom line: The patient was a 63-year-old man, Mr. Kim, who presented with fatigue and was found to have anemia with few comorbidities, mild hypotension and tachycardia and few other abnormal findings on exam. His hemoglobin was 6.
The student launched into his differential. He was positive it was an ulcer, but colon cancer, sickle cell disease, autoimmune hemolytic anemia and myelofibrosis were all possible. But really it was likely just an ulcer. His approach was somewhat disorganized. Obviously he was going for a trawling approach, casting a wide net of diagnosis and hoping to reel in a live one.
I suggested he focus his differential into the usual basic categories: blood loss, hemolysis or decreased production. Was the patient having hematochezia or hematuria? Any reason to suspect he might be exsanguinating? Perhaps a more detailed history would help, and some other labs as well. Was there pancytopenia? How about a stool test for fecal blood?
I turned to the intern. She smiled and explained that the haptoglobin was normal so the patient was not hemolyzing. I felt reassured. Again I queried whether anyone had spoken with the patient. Had he ever been anemic in the past, was he bleeding, any historic clues?
The resident stepped forward. He noted no pancytopenia. The red cell size was slightly large, and as a future hematologist he was sure this was likely to be sideroblastic anemia, though the alternate differential was large, and he began to recite it. Rocking slightly, as if in prayer, he spewed forth his diatribe.
We went to see the patient—a novel idea. As an intern, I had an attending who claimed she could learn more from a patient's labs than taking a history. The sensitivity and specificity of her physical exam were so low that Medicare had declined payment. Despite this, we proceeded. Relatively normal vitals, no rash, no purpura, no nodes, no organomegaly, no pain, no bleeding. Nothing. I was casting about for a clue, the consulting pressure on, but my line came up empty.
If in doubt, take a history. The patient will usually tell you what's wrong with him, or expire before you're done. Where was he from, what did he do, how did he feel, what was his dog's name, who was vice-president, menthol or unfiltered, tastes great or less filling? My usual set of queries. He was a car company executive working with a Korean automobile manufacturer, and he made many trips to Korea. His hobby was fly-fishing.
I felt the hook set. I asked him if he cooked a lot of his own fish. He replied no, but he did love sushi. The worm was on my hook and in his gut. I smiled and turned to the team. “Check his B12,” I said. “This man has diphyllobothrium latum, and he's got secondary megaloblastic anemia.”
The team stared at me. I reveled in their adoration, or maybe they were just staring at my ugly tie. I was reeling in the big one. I'd been chasing a patient with this diagnosis since medical school and I was about to land one. Finest kind!
Then the patient began to have an episode of emesis, bright red blood spewing in an ermine arc across my shoes. He was quickly transferred to the ICU, where a second-year medical student obtained a history of massive nonsteroidal ingestion. It was a bleeding gastric ulcer, just as I had suspected (ahem). I realized I was a fisherman, but my prey was less ichthyotic, more diagnostic.
Like an old man in a rowboat, hoping to land the granddaddy of the pond, I had felt that tug on my line, hook set, ready to reel in the diagnosis I had been fishing for, only to feel it swim away on an emetic river of blood. Once again, the big one had gotten away.
Dr. Newman is a hospitalist at Mayo Clinic in Rochester, Minn., and the editorial advisor and humor columnist for ACP Hospitalist.
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