Stone cold crazy.

Right after talking to my two Grady doctor-girlfriends about my "weird, nagging new hip pain."  With Stacy H. and Dominique C., Atlanta Women's 5K last Saturday.

Doctors make wretched patients. Or as one of my med school advisees says-- we make "ratchet" patients. Ha. I mean, sure, it may be slightly unfair to generalize in this way but I think most of us will agree that it's true. Not "wretched" in the sense that we are mean to the healthcare providers or ancillary personnel. No, not that. Just terrible when it comes to not trying to make our own assessments prior to seeking medical attention.

Well. Let me just speak for myself. I will go right on the record and say that I do not-do not-do not like being a patient. Matter of fact, I think my "do not" should be right up there with Sam I Am and his disdain for green eggs and their accompanying ham of the same hue. No, thank you.

Uggh.

That brings me to my recent brush with the flipped role. Yes. That. It underscores how difficult it is to be objective when it comes to ourselves or our family members and how, at some point, even us doctors who THINK we have all the answers need to submit to the fact that we DON'T.

And since I'm a total academic medical teaching nerd, I think, for the sake of my fellow medicine nerds of all ages, I shall present this in the form of a medical case. Kind of problem-based learning style. And hey! This means that all of you non-medical medical nerds who read this blog will get a glimpse of what we do in small groups and during resident/intern report.

*Please contain your excitement.*

Note that nearly all details are accurate. Except for the ones that I kind of had to come up with from memory like labs and such. But the general range is correct so just roll with me. Oh and I won't be sharing so many details that it just gets weird for all of us. That said, there is still learning to be gleaned from this.

Sho. Nuff.

Y'all ready? Let's go!

History of present illness

This 43 year old African-American female without significant past medical history presents with a chief complaint of "this weird pain maybe in my hip or groin." The patient was in her usual state of health until five days ago when she was running and noticed what she describes as "a discomfort" in her lower abdomen, groin, and thigh. The pain didn't appear to improve with ceasing activity nor did continuing to run seem to worsen it. She reports the quality of the pain to be dull and achy and states that it seemed to come and go. The patient was able to continue running and states that the symptoms mostly abated with 400mg of ibuprofen. She denies fever, chills, recent or remote trauma, nausea or vomiting. She has never had this kind of pain before.

Discussion #1

Alright. So let's come up with a differential diagnosis. And for you non-medical medical nerds, that's just a list of what we think could be possibly going on based upon what we've heard so far. Now. The goal in the differential diagnosis is to stay rather broad at first and then narrow it down based upon the additional details available to you.

If you are a doctor diagnosing yourself, however, you do the exact opposite. You decide what you think it is and then you just sort of shrug and keep going.

Differential diagnosis 

Musculoskeletal pain (ligamentous injury? overuse injury?)
Osteoarthritis of hip
Appendicitis
Ovarian cyst
Very early ectopic pregancy
Arthralgia
Something infectious involving the hip

Differential diagnosis if you are a doctor-as-the-patient

Some kind of hip osteoarthritis that I am praying I don't have at 43.

More history

Over the next few days the patient states that the discomfort continued. It seemed to be unrelated to activity or any precipitating event and seemed to be getting worse. Of note, however, she states that one day prior to the start of the symptoms she recently returned from a five day trip to the Mayan Riviera in Mexico. She reports having "the bubble guts you get after going out of the country" but has not had frank diarrhea, change in appetite or other significant gastrointestinal complaints beyond occasional cramping. There has been no blood noted in the stool or urine. There was no reported discomfort with urination or discharge of any kind. By the weekend, the patient states that the pain had worsened and that she was taking ibuprofen every 8 hours. She was able to continue her activities of daily living which included a 5K run on Saturday and several other activities over the weekend.

On Monday morning, the patient woke up with significantly increased discomfort. She woke up early and took some ibuprofen. She did notice some discomfort when walking but states that sitting down was equally uncomfortable. On a scale of one to ten she rates the pain at a "six or seven" --with a "ten" being childbirth. There was still no nausea, vomiting, or diarrhea although the patient did report decrease in appetite. She went to work and states that throughout the morning the pain was distracting her from being able to concentrate.

Differential diagnosis if you are a doctor-as-the-patient

Ah hah! Maybe this is some kind of reactive arthritis in my hip after going to Mexico and contracting some kind of GI bug. Ah hah! I'm so smart!

Plan

Call my friend who is an ID nerd to see what she thinks about that possibility. And then find out what she thinks I should do about it.

Differential diagnosis from ID nerd friend while driving to work

"Nope. Doesn't fit reactive arthritis. Maybe the action isn't in your hip. What if this is like . . I don't know. . referred pain from somewhere else?"

Sidebar:

"Referred pain" is when pain originates in one place and goes elsewhere. This is particularly significant when we are talking about things involving organs in our body. Kind of like how you can have gallbladder issues but feel pain behind your shoulder blade.

 More history

The patient sought medical attention. And by medical attention that means that she went to the office of her good friend, the Ob/Gyn-med school classmate during the lunch hour. At that time a full exam including bimanual examination of the ovaries and a pelvic ultrasound were performed without any evidence of adnexal (adnexal = "over by your fallopian tubes and stuff") masses or asymmetry. This also did not exacerbate or reproduce the pain. A basic metabolic panel was obtained which demonstrated normal electrolytes, blood glucose and kidney function. A urine pregnancy test was negative. A urine dipstick revealed 1-2+ hemoglobin, but was otherwise normal. (hemoglobin in urine = some blood in the urine.) Of note, the patient was not menstruating.

Differential Diagnosis from the Ob/Gyn-med school classmate

Not an ovarian cyst
Not appendicitis
Not a hip or musculoskeletal issue
Not an ectopic pregnancy

Maybe a kidney stone?

Differential diagnosis from the really annoying doctor-patient

Not a kidney stone because they're supposed to hurt so bad that you can't do anything but scream and demand things like Dilaudid.
Are you sure you got a good view of my ovaries with that ultrasound probe? Can't it still be an ovarian cyst?
Blood? Chile please. Let me see that urine dipstick to make sure you're reading it right.


 Plan

Ob/Gyn-med school classmate decides to rule out nephrolithiasis or urolithiasis (stones.) Her reasoning is that the combination of probable dehydration whilst basking in a near-equatorial sun whilst hydrating with non-H20 (not to mention sort of avoiding H20) could have predisposed the patient to this. Furthermore this could serve as a unifying diagnosis for the nonspecific quality of the pain, the colicky nature of it, the inability to find a comfortable position, and, of course, the hematuria. 

CT abdomen and pelvis without contrast, stone protocol
Formal ultrasound of abdomen and pelvis



Next

The patient subsequently is scheduled for imaging studies which she promptly has done and then read thanks to the awesomeness of Emory Radiology.

Assessment:

1.  Nonobstructive kidney stone--now passed into bladder.
2.  Ovulation on right.

Plan

1. Hydrate, hydrate, hydrate. Preferably with water and not Mexican beer.
2. Follow up with primary care physician to demonstrate clearance of hematuria.
3. Hydrate, hydrate, hydrate.


Discussion

Okay. So let's just get this straight. This crazy 43 year old woman worked all week, ran a 5K with a PR, hauled her kids hither and thither, went to a black tie/formal event, hung out with her mama, worked in clinic and went to meetings on the day of assessment--all while passing a FREAKING KIDNEY STONE.

Hello?

How many stories have y'all read about women working all day or like building a house for Habitat for Humanity or something while in full-blown labor? They arrive at the hospital 9cm and completely effaced and they just say, "I was sort of feeling not that good. I wasn't sure what was going on."

Errrr hello?

What was going on in that example and in this case was what often happens not just with physicians but with a lot of women. We take care of everyone else but throw ourselves on the backburner. We suck things up--even when they are CLEARLY out of whack--and chalk it all up to "this too shall pass."

No pun intended. Although that is kind of witty. "Pass" -- get it? Like a stone? Passing? Bwah ha ha ha!

*cough*

Okay, where was I? So if you are in the medical field and/or know anything about kidney stones, you are shaking your head incredulously. You may or may not be perusing my last post and realizing that yes, on all of those images, I was fighting that "mysterious hip pain." But dealing with it because of my pure lack of objectivity when it comes to my own symptoms.

So. What is the take home, young grasshoppers? I'll tell you that it's NOT for you to think it's BAD ASS and ignore your body when it is telling you something. That's definitely not it. Let this be a reminder to all of us nurturing types:

FIRST PUT THE OXYGEN MASK ON YOURSELF.

Or in other words, see about yourself. Stop blowing stuff off. And don't minimize everything. Kidney stones can cause obstruction and renal failure. They can be medical emergencies. So can a lot of the things in that original differential diagnosis. Plus I had NEVER had pain like this before and it was of an unusual quality. I should have sought medical attention. At least three days before I did.

So yeah. I will try-try-try to do better. I promise I will. But this proves that the old adage about doctors being extraordinarily shitty patients is true. And okay maybe the adage doesn't say "extraordinarily shitty" but you get the picture.

Lastly, let me say this:

Sitting in a waiting room to get a CT scan is humbling. You see people that clearly are chronically ill, battling cancers with their chemo-induced alopecia to show for it and even little children wearing fuzzy slippers wrapped in the tired, worried arms of their parents. Health is not something to take lightly. I recognized while sitting in that chair awaiting my turn that I could be moments away from some life-altering or even life-threatening discovery. And maybe even one that, had I seen about myself sooner, could have been reversed or easily treated. There's nothing about me that makes me any more entitled to being well than anyone else sitting in that room.

Nothing.

So yeah. I tell you all of this tongue-in-cheek. But really, it was some terrifying stuff in a way. I take care of mortals every day. Yet I am one. One with lots to live for just like all of the people I see. Just like all of them.

***
Happy Wednesday. I feel much better, y'all.

Not too shabby for a lady passing a kidney stone, right?