Dr. James Knutson: Working to find the right diagnosis for young girl epitomizes first four weeks

     People ask me how my intern year is going, and I think this entry is a case-in-point. Four weeks have already gone by, and I've finally found a free moment to take note of some stuff. There's also letter and packages waiting to be mailed, and phone calls from mom that need returning - something about time management comes to mind.
     This week was especially tough, probably b/c my week started Sunday morning on call. Things were going smoothly until I got a call about one of my colleagues patients - young girl w/ a headache, shouldn't be a problem. That is, until I read her chart and realized her constellation of symptoms didn't fit any clinical picture:
     1) abdominal pain - was it appendicitis (which means emergency surgery) or just cramps?
      2) low blood counts - cancer, autoimmune disease, or simple anemia?
      3) "worst headache of my life" - a bleed in the brain (but she had a normal head CT scan that morning) or meningitis?
     We needed to evaluate her headache, and to diagnose meninigitis requires a lumbar puncture (LP), a procedure that sounds scarier than it really is (probably easier for the person holding the needle to say). However, her platelets (the cells that help blood clot) were low so she needed a platelet transfusion - but transfusions can make some autoimmune diseases worse. Rarely does real life medicine resemble TV medicine - "either we do X and she lives, or we do Y and she dies." And yet when you don't know the diagnosis, it sure can feel that way.
     By then, it was time to sign out to the night shift - we agreed that before we gave platelets, I'd run down to the lab to look at her blood smear to see if her immune system was chewing up her cells. I had already changed into my street clothes, and it was long past time to go home, but there I was in the lab, hunched over a microscope, not seeing any "schistocytes," chewed-up cells. Give the platelets, do the LP, and hopefully we'll have our diagnosis by morning.
     I left feeling a little better that we had a plan, but not knowing someone's illness is scary, especially when it's a healthy patient with loved ones who are also scared. When I got home, I looked at the clock - my alarm would go off again in 5 hours. I think I spent those 5 hours divided between "wide awake" and "nightmares."
     I hope she's OK.
      -- Dr. James Knutson, resident