The Price Is Right

Recently, I had the opportunity to cover at the clinic of one of my mentors while he was out of the country and it was a taste of how private practice would be like.

First and foremost, I was not under any illusions that the patients came to see me. It was my mentor's specialty they were there for. But I'd like to think he and all the doctors I was fortunate enough to learn from during my residency, taught me well. In my one-week stint as a pseudo-neurologist/internist, I had a day wherein I earned P3,500 for a two-hour stay at the clinic seeing consults (if the BIR is reading this, yes, I pay my taxes).

No, everyday wasn't like that, but that was the best day I had -- pay-wise and learning-wise.

I had a patient come in who was recovering from TB meningitis after suffering through it abroad. He had hydrocephalus and underwent an insertion of a ventriculoperitoneal shunt, a V-P shunt for short (a tube that drains the fluid from the brain into the tummy). He was doing fine, his mom was due to go back to Taiwan, and his meds were all in place. Another patient came in for her first follow-up since suffering a mild stroke. She was a pleasant lady and was fortunate enough to be walking and talking. She had a lot of questions and we went through all her medications one by one. She wanted her next follow-up to be with me, and I sheepishly said that my mentor would be back in a few days, and that she would be in good hands (later in the week though, she called the clinic to relay her INR looking for me and I adjusted her meds but her follow-up would still be with her primary attending).

But the prime case of the day was a woman in her late fifties who came in with her husband and kids with the complaints of memory loss and disorientation. She was a hypertensive who self-medicated with a beta-blocker with poor compliance (when she felt like taking meds only, like most people).

So I investigated and went through the interview and examination. I found out that just a few days ago she had dressed herself with a blouse and went out, but forgot to wear a skirt (thankfully, it was just up to the living room where her family brought it to her attention). She had, on occasion, used a banana instead of a spoon. She forgot the names of her kids and she was noted to be walking more slowly everyday.

Her BP was through the roof on 4 separate measurements (after the 2nd taking, I already ordered a wheelchair be brought up so she could be admitted). There was no obvious deficit in strength and no right-left asymmetry. By this time, I talked to her husband and eldest daughter that she really needed to be admitted or at the very least, undergo a CT Scan. I finally convinced them after giving them the worst-case scenarios (scared them into the decision, maybe, but I look at it as finally getting them to trust my judgment). While waiting, I proceeded with several more tests, she couldn't do serial 7's (100-7, 93-7, 86-7, you get it), calculations and had agraphesthesia (inability to recognize numbers or letters traced on the palm).

I explained that with all her manifestations, she could be having or had a stroke. Silently, I thought, most likely ischemic in origin, parietal lobe in location, of the dominant hemisphere. The wheelchair came and took her to the emergency room, where I hoped that the resident on duty would be astute enough to recognize the need for a CT scan as soon as she arrived (all stroke patients should be scanned within 40 minutes of ER arrival, as much as possible).

After finishing all the patients, I went to see the scan and found out I was right! An infarct in the temporal-parietal-ish lobe , or at least that's how it looked to me. It was a bit well-circumscribed so I wasn't surprised that the attending physician thought it was a mass. I asked the medical resident who had conferred with the attending, and they all thought it was a mass (I don't know if he was just relaying the reading, or if he had an opinion) and an MRI was done. I confirmed with the radiology resident, both the CT and MRI scans showed an infarct.

You see, I am a case junkie. I love my patients and I treat them as people, but, separating them from their diseases, I look at their cases in my mind as cool puzzles to solve. And when I get one right, it's gravy. It's like Tiger Woods a couple of years back pre-scandal, when he would do a fist pump to celebrate the birdie he just sank, or Michael Jordan sinking a jump shot over Bryon Russell to win the game.

If anything else, I feel the self-satisfaction of getting the diagnosis right to help other people.

I was going over the experience with my wife in the car and concluding the conversation with P3,500 I earned for the day and she calmly said, knowing the answer and more stating a fact than asking a question, "Well, which would you rather have, the P3,500 or that you got the diagnosis right?"

I smiled. I knew she had the right answer.

Thankfully, that day, I had both.