Medicine

If I didn't choose anesthesiology, I'd be an internal medicine doctor. Although there are many things about the field I didn't like - and I ultimately chose not to go into it - I do miss some aspects, especially differential diagnosis. My last admission to the ICU was a fascinating medical conundrum. He was an elderly gentleman found with altered mental status. No one knew his medical history, medications, or anything about him. He was confused and oriented only to his name and age. He couldn't tell us where he was or what year it was. He kept on perseverating on odd subjects like his high school or his brother. On admission, his vital signs were completely normal - no fever, heart rate 95, blood pressure 120/60, normal oxygen saturation on room air.

But he was ultimately admitted to the ICU for several odd reasons. His blood counts showed a white blood cell count of 1,000, a hemoglobin and hematocrit of 4/11, and platelets of 60,000 - all of these were extremely low. His kidney function was poor with a creatinine of 1.7 (with an unknown baseline). His INR - a measure of coagulopathy - was elevated. A CT scan showed that most of his intestines were up in his chest in what was called a Morgagni hernia. What was going on? No one really knew. The decision to admit to the ICU was pretty soft, but I took him.

Trying to tease everything out was very fun. This is what internal medicine physicians live for. Was this a problem with bone marrow? Did he have a primary malignancy somewhere? Could this be occult liver disease? Or a state like TTP-HUS? Did severe nutritional deficiencies or hormone imbalances present like this? Or some strange atypical infection? What drugs and medications could be playing a role? Was his confusion due to the other things going on in his body? How did this weird hernia fit into the picture? In the end, I sent a panel of tests that ranged from a blood smear to copper and zinc levels to protein eletrophoresis of the urine to thyroid function studies. I hope that the hematologists and probably a bone marrow biopsy will give us the answer.