My Quora Answer to:
As a doctor, what was the strangest, most obscure disease you’ve diagnosed?
OK, you just gave me the opening for one of my favorite stories. Thanks.
"The Wurst Pun Ever"
I was doing my clinical rotation in the Emergency Department at Waukesha Memorial Hospital during my first year of residency. A forty-something woman presented with right upper quadrant (RUQ) pain of three months duration. Specifically, I used the “PQRST” technique to elicit answers and hopefully lead to the correct diagnosis. This is a mnemonic and as I've mentioned before, physicians live and die by mnemonics.
(P) Palliative/Provocative. What makes the pain better and what makes it worse?
In her case, lying supine (on her “s(u)pine”) made it worse. As did eating spicy and greasy foods. Poking (palpating) her RUQ did, too. The pain lessened in an upright position.
(Q) Quality of the pain: sharp, dull, achy, crushing, etc.
Sharp. There was also a chronic, underlying dull pain.
( R ) Radiation. Does the pain go anywhere else? If so, where?
The sharp pain only radiated to her back.
(S) Severity. On a scale of 1-10, 10 being the worst pain you've ever experienced, and zero no pain.
The chronic dull pain was a 3-4 while the sharp pain was a 9. In her life, having kidney stones was a 10 and giving birth an 8.
(T) Timing. How long have you had it? Is it constant or intermittent? If intermittent, how often does the pain occur and how long does each episode last? Have you had it before and if so, when, and for how long?
My patient had the pain for about three months (she couldn't be more specific than that). The dull pain was constant, and the sharp, intermittent. Those episodes lasted from a few seconds up to a half hour.
She had seen her family physician Dr. Braunschweig, three times since it started. Each time he prescribed her an antibiotic since his Presumptive Diagnosis was a liver infection. In that time span, he never ordered any imaging studies, but a Liver Panel he obtained was “within normal limits” or WNL. He had the correct body part but the wrong diagnosis and therefore, treatment.
After staffing the case with the ER Attending Physician, I ordered a CT of my patient's liver. It revealed an abscess, a very rare finding and one more prevalent before antibiotics were used to treat gonorrhea. I wasn't aware at the time of the association between this STD and liver abscesses so never asked her about prior infections. Anyway, the cure was open belly surgery (“laparotomy”) to incise and drain (I&D) the abscess, followed by the appropriate antibiotic. There is a saying in Surgery that “the cure for any abscess is an I&D,” and another, “if it can't be cured by surgery, it can't be cured.”
So, get ready for this. Sit down if you can. The moral of the story is:
“The patient went to see Dr. Braunschweig for right upper quadrant pain, but he only made her liverwurst!”
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