Monday, December 9, 2013
Look Before You, Uh....Cuddle...
Look Before You, Uh....Cuddle...
Can you tell the difference between something which is let’s say bony hard and something else which is stony hard? I mean how hard bone is and how hard a stone? Can you tell the difference by feeling with your hands, just your finger tips, eyes strictly closed? Well if you are able to do so, congratulations you just passed the general surgery paper. Hold on, wait a minute, before you start throwing things at me and let me explain the above example. Contrary to what is generally believed in surgery- treatment is only half of what you do, the other half- shall we say the better half- is diagnosis, the finding out of facts and deciding whether they are worthy of being operated on or simply require drugs to cure. No one wants to undergo unnecessary surgery do they? And that’s the reason learning diagnostic skills plays such a large part in medical training. If you can see it- you can kill it (probably) a concept which predates drone warfare
But there are diseases and diseases- some common place, some rare enough that you read about them only in text books and suddenly remember a particular line from the book staring at your face when quoted by a patient to you out of the blue. Your mind goes "oh wait, i know this, I know, now where did i read this? Which subject? Which book? Was it in so-and-so textbook? Yep I think so. So let me confirm it by going along that path and asking more questions". And that’s how the diagnosis for most of the common diseases gets done. But sometimes, rarely, no one knows what the actual disease is but we can still identify the symptoms and treat the disease without putting our hand on which specific organism actually causes the disease till the lab results come out positive and then you go "Hold on, oh shit, this one? Isn’t this a zoonotic (animal) one? How did it ever.....?" And based on those test results you start asking the patient specific questions like "how many pets do you have at home? Do you ever pet wild and rabid animals on the street out of the goodness of your heart?" and the answers finally make some sense.
So the story i am about to tell you started a couple days ago when i was a referred a patient for opinion on her enlarged lymph nodes in the neck area. In India any enlarged lymph node is automatically (and rightly) suspected of being tuberculosis. But identifying Mycobacterium, the organism which causes Tb is fairly easy - you just need a chest x -ray or like i said in the first para if you can put an hand on the enlarged lymph node and press it down and it feels rubbery firm then you can suspect TB and go on to order blood tests. At the risk of repeating myself diagnosing mycobacterium tuberculosis is easy but treating Tb is a different kettle of fish- that mycobacterium is one tough sonofabitch and doesn’t die easily.
Anyway to return to my story once you rule out TB as the cause of enlarged lymph nodes the next obvious suspect is a cancer - lymphoma, thyroid cancer and stuff like that. And again as I said in my first para, if you start pressing the enlarged glands and find them to be stony hard and fixed to a point -then you scratch your head and wonder how you are going to break the news to the patient that they "might, just might" have cancer pending further tests to confirm. But for this particular patient the diagnosis of cancer was ruled out because the doctor who had seen her just before he sent her to me had taken a CT scan which pretty much ruled out cancer as a possibility. He suspected an infection and he sent her to me.
I suspected an infection too- a chronic or longstanding infection - but like all the other doctors who had seen her before me I just couldn’t pin her down to which infection. So as i always do when in doubt, i went back to the beginning. I sat her down in front of me and asked her to tell me the whole story right from the beginning and assured her that there was no hurry and we had all the time in the world as if she was my only patient for the day. And that’s how i got my first glimmer of a diagnosis when she talked about her initial flu-like fever and a few weeks later developing those swellings and as she went on and on I suddenly noticed the profuse white hairs scattered all over her black salwar dress. The patient before me was in her mid-20's and still had most of her hair on her head and i could no way think of any reason why she should have so much hair fall in a single day- besides her hair (even if dyed/colored) was still black while the dress was covered in white hair. Voila...the violins sang somewhere and I had cracked the case in my best Hercule Poirot style.
"Do you have any pets at home" I asked interrupting her long story of how she hated eating only bread due her fever. "Yes" she said, "I volunteer with the animal adoption drives on facebook" she said and then continued "I have two cute little kittens at home, they very cute and playful animals doc, they can never be separated from me, they even sleep on my chest at nights" at which point I removed my spectacles (TV doctor style) to peer at her and then i wagged my finger at her (couldn’t resist) and said in my best i-am-the-expert voice "Ah, Ah, You have a zoonotic disease passed from animals to humans. It might be Ebola- in which case you should be dead by now, might be Crutzfeld-Jakob - in which case you will go mad before you die. Anyway let’s send you for a blood test for the most commonest cat disease- Toxoplasmosis" and then i wrote her a PCR test for Toxoplasma gondii- a parasite which usually lives in cats but sometimes infects the cats owners too.
The rest as they say is history - the PCR test came back positive and we started her off on Clindamycin and Pyrimethamine- all good solid parasite killers which can take care of a little parasite called t.gonddi without breaking a sweat. And I sent her back with a warning to stop cuddling with those cute little kittens all the time (especially at bedtimes) and instead get a man to keep her bed warm at night (actually I didn’t say that outright but sorta implied it). I further pontificated generally on how dangerous animals are to human beings who don’t recognize the truth and gave a few examples like - bird flu, swine flu and HIV all of which had come to us humans (mostly to single ladies) courtesy of those cute little animals.
And that’s the point of this post. Actually there is no point to this post, but if you are still reading this the take home message is - stop cuddling animals and go cuddle with other humans.