thumbs down...

The thing that I do like about Internal Medicine, or Family Practice, is that I get to see the end of the story, instead of being left with endless cliffhangers like in the ER.

It was always like I got to watch half of a movie, and just when it was getting good, just when I was hooked, some jerk turned off the TV... or the sattelite cut out, or the DVD was scratched beyond repair. I once actually had lightning strike right outside the door of my place where I was watching a movie, not 20 feet away. It fried the VHS right in the VCR. (yea, it was in the VHS days.) That was a serious let down... what happened to the protagonist? did he get the girl? did he achieve his seemingly impossible dream? did he survive the barrage at Bastogne? who knows..... and now that the tape's fried, you're not gunna.

well, that's how it often was in the ER. we could often figure things out, stabilize and such. but even with a diagnosis, there was often further workup and treatment. I never knew what happened to these folks. Did the guy with the AAA we found make it through surgery? Did the lady in DKA ever get out of the ICU? well, who knows... so pop in another movie... 37 yowm, overdose, just barely breathing...... wonder how this one will end. however it ends, i'll never know.

But in the clinic, I get to see page one to page done. well, at least for certain things. Diabetes isn't ever going to just end... COPD... these things go on, but there are tenable endpoints and concrete answers to certain questions here.

Take for example my 31 year old male who came in a few days ago for leg pain. He had run home from work a few days ago, and woke up the next morning with what he said felt like a pulled groin. So he'd been trying to take it easy, but still had been going to work where he's on his feet all day. So now his calf and part of his hamstring were bothering him. He figured he'd been sort of compensating for his hurt groin... walking differently, using different muscle groups.

Well, this sounded about right to me. His history sure made sense for this, and his physical was pretty normal, his calf was awfully tender to palpation though... awfully tender. and is that R calf looking a bit larger than the L? hmmm.

I go back and talk to my preceptor, who's an awfully good PA, and told her what I found on HX and PE. I told her what I thought it was, most likely, and what I wanted to do. (On a sort of side note, she asked me what I thought about Homan's sign, and I said it was bogus... that it had a low specificity and sensitivity, so I didn't do it. Thank you Prof. Randolph.)

So we go back in there and tell him that we are going to give him something for the pain, that it's most likely a musculoskeletal injury like he thought. We went on to tell him that to be on the safe side, we wanted to send him for a right leg ultrosound to rule out a DVT.

Tick, tock.... tick, tock.

A few more minutes pass in the movie.... our protagonist is off to battle.

A few more minutes elapse on the DVD.... (2 days pass) and our hero returns.... I see him limping through the waiting area. It seems his wounds aren't yet healed.

He arrives to the nurses station, looks over at me, and after a smile and "Hey!" from me, he smiles back, but gives me a double thumbs down as he shakes his head.

I already know what has happened.

"Not good news, huh..." I sigh.

"Nope." he replies, with a sort of sad smile.

"I'll be in to talk to you in a minute."

It turns out that our friend did actually have a popliteal DVT. Which explains the extreme tenderness to palpation of his calf, worse as you neared the popliteal fossa. It also explains why his right calf appeared a bit more swollen than his left.

He had already been started on Lovenox the day prior, right when he got the diagnosis (an anti-coagulant for you non-geeks.) and he was here for another round of shots, 80 mg subQ of Lovenox. We also started him on Coumadin (another anti-coagulant, but one you can take in pill form.) so we could get him off the heparin in a week or so, once the Coumadin was in its therapeudic range.

He's only 31 years old, a 5 pack year smoking history, (a kind of wimpy smoking history). NO other risk factors for DVT. This meant that our movie is not quite near the end.

We needed to do some more looking.... this meant bloodwork for things that could cause a hypercoagulable state, one of the most likely being a coagulation cascade factor mutation called Factor V Leiden. So we got more blood from him, sent it off to lab, and sent him home.

The story will continue tomorrow.

Lets pray this isn't a 'Lord of the Rings' trilogy... Let's pray it's a shorter movie... shorter is better for this hero. Lets pray that this movie ends with a Factor V problem, he can live with this. If everything comes back clean, and the movie gets longer, it's because we need to go cancer hunting... I don't want to go cancer hunting.

I'm in the mood for a good thriller of a movie, some mystery, some suspense... but I'm a sucker for a happy ending. I live for the happy ending.

I'll let you know if this has a happy ending. But at least I get to see the rest of this movie, because I'm hooked.

*the previous story is HIPAA compliant. names have been excluded, dates, sexes, ages and such have been changed to protect the innocent. (and they always will be on this blog.)*