|Year : 2022 | Volume
| Issue : 3 | Page : 210-212
Doctor as a detective: Musings from a long innings of clinical practice
RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
|Date of Submission||04-Jun-2021|
|Date of Acceptance||13-Jul-2021|
|Date of Web Publication||12-Jul-2022|
Dr. Raghavendra Bhat
RAK Medical and Health Sciences University, Ras Al Khaimah 11172
United Arab Emirates
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhat R. Doctor as a detective: Musings from a long innings of clinical practice. APIK J Int Med 2022;10:210-2
This is a narration based on a long and interesting clinical career involving private practice and teaching. This dates from 1982 to 2015 and involved actual contact with patients. To be in clinical practice for long and see similar clinical situations, the first requirement is to like interacting with people. Each person is unique – likes, dislikes, approach to life, way of interaction, and response to situations are variable and many a time unpredictable. One gets to see gamut of personalities and reactions, which range from serious to hilarious keeping one glued to the career.
It is very important to break the ice with a lively conversation. This helps us to communicate well and elicit a good history. The very first thing I invariably did after taking a history was to “measure” the patient – yes – very few parameters are measurable height, weight, temperature, heart rate, and blood pressure (BP) – most of them seem mundane and routine. The patient's response to the checking of weight helped me gain an insight into his personality. Some just climb up the weighing machine without any reservations. The really obese ones remove every detachable thing – shoes, belt, chain, shirt and even ring, glasses, and socks – then there is a moment of hesitation before climbing up – the patent whether the weight has gone up and me whether the machine will withstand the weight! After getting off, invariably they will blame the gadget for “inaccurate” reading – blaming it for the error – showing at least 5 KG extra! I really enjoyed the whole thing! There was some unintended humor too – a lady once asked me earnestly “My luggage please!” After a while of thinking what she is referring to it suddenly dawned on me – she was simply asking what her weight was!
I not only did not avoid house visits but also loved them too! I once called on a young girl aged 13 who never crawled – leave alone walk – due to muscle disorder since birth. The family thought her proximal limb muscles have become weaker recently. On calling up to her residence. I found a cheerful girl intelligent and cooperative. For a person with such a disability, her outlook was positive. Examination revealed a genetic muscle disorder and congenital heart disease. Her outlook despite all these was rather positive. Her diet was same as usual. Why then her proximal muscles were getting weaker? The answer was not hard to find once I saw her in her natural surroundings – there was hardly any exposure to sunlight– obviously Vitamin D was inadequate resulting in Osteomalacia where typically presents with proximal muscle weakness! Replacing Vitamin D would surely help her by improving the power in her muscles to some extent but there would never be a cure. What impressed me in this case was the positive outlook of that girl despite knowing there will never be a cure. I learnt something that day – the outlook necessarily does not depend on the outcome!
The night visit on a rainy day was even more challenging. I responded to a call from a lady on a rainy night saying her husband was dying and needed help. When I reached there, I found him lying unconscious half in the washroom and half in the bedroom. His breathing was labored and BP higher than normal. He was not responding but sweating. I asked the wife to show the medicines he was taking. Among other process, there was a strip of a long-acting oral antidiabetic drug from which 2 tablets were missing. To the best of my knowledge, he was not a diabetic. Then what was it doing there? Suddenly the things fell in place and his wife understood that I had it figured out. She said, “I called you to see he is terminally ill. You may now leave; I will collect the death certificate tomorrow.” I was in a very delicate situation– a clear case of attempted homicide and worse still, I had to certify it as a death due to natural causes. He could still recover completely if helped now. I had to think fast. I got out, knocked the neighbor's door (whom happened to be my primary school classmate). He quickly understood the situation and both of us shifted the patient to the hospital and much to the dislike of the wife; he recovered completely from the low blood sugar state (due to oral antidiabetic drugs given clandestinely by the wife with the intent to kill).
If you are considerate and do not mind seeing some poor patients who cannot pay your regular fees, you end up seeing some very interesting patients. You also get to know the beliefs, culture, and rituals. An unmarried girl was brought for consultation from a village. She had amenorrhea of 3 months duration. The village head accompanied her. They had decided that she was pregnant without being married and so was “impure.” They wanted me to confirm it so that they can suitably “punish” her. She said she never had any relation with anybody. Sadly, no one believed her. I had to do something to help her. They were very poor to afford any investigations such as abdominal ultrasound or urine tests for pregnancy. I got an abdominal X-ray done and paid for it. I was in for a pleasant surprise – the X-ray showed a small radiopaque shadow – A tooth in the pelvic region! It was a teratoma. I told the village headman that she was not pregnant. He understood and she was declared “pure.” This possibly saved her from severe punishment.
Some situations are unforgettable. When my friend and his wife returned from their honeymoon, the wife was in a very bad shape. She could hardly walk. He requested me to see her at home. I found her confined to bed. There was a container in the room, which contained her urine indicating she was indeed too weak even to use the washroom. The whole thing according to the husband started after taking a couple of tablets of co-trimoxazole for honeymoon cystitis. Abdominal pain and vomiting started soon followed by extreme weakness of the legs. The sunlight was falling directly on the urine, which was of “Port wine” color. Suddenly, it all added up. Co-trimoxazole, abdominal pain, extreme leg weakness, and port wine colored urine on exposure to sunlight could mean only one thing – Acute Intermittent Porphyria, which I thought only, existed in books! As the years passed, I realized we end up seeing all unusual and rare situations. One must be aware of them, read about them, and wait for them. After all, eyes only see what the mind knows.
It was a rainy night when a young man rode to the hospital on his bicycle. He was complaining of pain in the right axilla and vomiting. A chest X-ray was taken and it showed what they called “multiple fluid levels suggesting multiple lung abscesses.” I was requested to have a look in. I found that there was absolutely no history of cough – only chest pain and vomiting. Looking at the chest X-ray, I realized that these fluid levels were actually from the intestines. Something was horribly wrong – The right side of the chest was full of intestines! What did it mean? Many things – for one there was no right lung. Then what was causing the pain on the right side of the chest, in the right axilla? If the intestines are there, the pain could be from some portion of the intestines – inflamed. What is the most likely portion? Appendix of course! Therefore, I diagnosed thoracic appendicitis and called my teacher – a very capable surgeon at 3 AM in the morning. He said he has not only not seen one but also had not even heard of one! He asked me whether I was fully awake! Convinced I was, he came in and operated. “This is the first thoracic appendicitis I have ever seen. I compliment you on your perfect preoperative clinical diagnosis!” It is one of the best compliments I ever received! Goes to prove observation and logic go all the way in the “Medical detection” process.
This incident happened just after I began my private practice. I was called to the house of an 84-year-old very well-known man who developed sudden onset of abdominal pain and back pain. His lower limb pulses were hardly felt proving my worst fears – The most likely diagnosis was rupture of the abdominal aortic aneurysm. He wanted to know what it was. I had to tell him the truth and the need for a quick transport to a advanced medical center. This was an excellent clinical diagnosis but it called for a quick second opinion as with more and more blood loss death would follow. I called in a senior surgeon myself for a second opinion. He agreed with my diagnosis but could not convince the patient to move to a hospital. The old man had a peaceful death at home. It is not only important to diagnose emergencies accurately but also inform the patient's kith and kin about possible death. If they refuse treatment despite all explanations, it is indeed safe to take a second opinion and document the same. I followed the same steps whenever I was confronted with a patient with a terminal or irreversible disease.
Students often complain about the inability to get drug history in chronic diseases such as TB where this is very important. Doctor really has to be a detective here. If the urine is red, the patient I taking rifampicin. If the opened tablet melts on exposure to air, it is ethambutol. One tablet is very cheap – that is INH. One is a tablet, which can cause pain in the knee joints – that is pyrazinamide. One is a painful injection – streptomycin. This gives a good insight into the regularity and adequacy of treatment and clues to possible reactivation or resistance to drugs.
Good communication is a very important requirement for a successful interaction. Communication not only means speaking – it also involves body language, gestures, and most importantly, listening. I had a particularly interesting patient who was deaf and dumb. We could understand each other very well. The language or lack of it was never a barrier. He has a massive tobacco addiction – he would gulp a lot of concentrated tobacco and develop angina. Electrocardiography (ECG) on arrival would show ST-segment depression with T wave inversion. After a “chat” in sign language that both of us understood, his ECG would be normal at the end of our chat and he would go back happy and smiling.
There was a funny instance in which the psychiatrist referred me a patient with a letter saying, “Where is the heart attack?” The patient was taken to him for depression. The BP was elevated a little more than normal. ECG was normal. Creatine phosphokinase (CPK) was estimated as a part of the workup and it was more than 2000. Fearing it to be a heart attack (because of the report of grossly elevated CPK), the psychiatrist thought it fit to refer the patient to me. In fact, in the early 1970s the CPK elevation was found in the situation of hypothyroidism. Later, it became a tool for the diagnosis of heart attack until troponin T took over. Obviously, the elevation of CPK was connected with muscle involvement due to hypothyroidism and had nothing to do with the heart! I sent a funny reply saying this was no “heart attack” but a “thyroid attack!”
These are only a few illustrations to drive home the message that being a “detective” is important as it makes the day more interesting and enables a more intelligent interaction with the patient rewarding both the doctor and the patient!
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There are no conflicts of interest.