And the CT scan shows…


The patient came in feeling sick

With sputum so bloody and thick

That I ordered CT

And pneumonia I did see

And new drugs I then had to pick

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Last week I saw a patient with the chief complaint of hemoptysis (bloody sputum).

Blood from the nose might be normal, and frequently people confuse bloody post-nasal drip with blood from the lungs. In this case last Thursday I viewed with alarm the large amount of blood in the paper towel the person carried.  Despite a normal chest x-ray from a few days before, I ordered another.

A large part of my job consists of thinking of the worst thing possible; in this case, a blood clot in the lung. I also had to consider cancer, pneumonia, and tuberculosis.

The repeat chest radiograph came back as no change from the first: nothing worth writing about and certainly nothing to explain the hemoptysis. I thought things through.  Back in Iowa I would call the pulmonologist and ask whether or not he wanted a CT before the consult.  Here I had to consider the risk of flying to Anchorage.

I hesitated about the CT for a lot of reasons. As a profession we use too much technology, too much radiation, and not enough thought.  But the more I thought, the more I knew I had to make sure the patient didn’t have a blood clot in the lung.

Despite a normal plain x-ray, the chest CT showed a dense pneumonia. In short order, I consulted an on-line data base and several docs who work here and know which antibiotics will likely succeed.  The first antibiotic, obviously, hadn’t worked, and I eliminated it from the list of options.  I ordered a series of 5 daily injections, started testing for TB, and added in doxycycline, an antibiotic that dates back to the 1950’s, but, strangely, has kept good activity.

I found it hard to recognize the patient at the first appointment of the day, feeling and looking much better, pain free, and breathing easily. I asked for, and received, permission to write about the case, and the intense personal satisfaction I get from seeing a patient improve.

Tuberculosis remains a problem in this area, despite very good drugs to treat it.  On morning rounds before clinic I received the benefit of my colleagues extensive experience with a problem rarely encountered back home.

But then I presented the group with information about acamprosate (trade name, Campral), a medication to cut the cravings for alcohol. As with any treatment for any addictive disorder, it has limited success.  One can treat the physical side but trying to address the enormous complications of dysfunctional sociology can be problematic.  I felt grateful to be able to add to the group’s knowledge, rather than just taking away.

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2 Responses to “And the CT scan shows…”

  1. Jacqui Says:

    Hi. Found your blog this morning, starting to read though. I wonder, in your experience chatting with patients suffering B12 def and PA, have any mentioned feeling worse during high temperatures in the summer months and during/after air travel? Do any seem to burn through the B12 faster during summer or when they try to increase their exercise? I note that your temps in Alaska (holy mackerel, really that cold?) do not actually get high like Australian temps, but I see that you have worked in various places around the globe. I am also curious about hormonal fluctuations in Peri-menopausal PA sufferers and how that figures with neurological and physical symptoms. Any thoughts would be welcomed. Many thanks.

    • walkaboutdoc Says:

      When I hear about people with neurologic symptoms (like fatigue) that worsen in the heat, I worry about multiple sclerosis (MS).

      When I see the abbreviation PA, I think about posterior-anterior, Pennsylvania, and prior authorization, but not a specific disease. In what sense are you using the term PA? Is it psoriatic arthritis?

      Yep, here in Alaska temps in the winter regularly go below minus 40, when Centigrade and Fahrenheit are the same. It gives me a moral justification for having real wolf fur trim on my parka. However right now I’m in the southern coastal areas and it’s been a very warm winter with not much snow.

      Some people need more B12 than others, one patient took a milligram every 3 days and barely kept a level above 300. I haven’t noticed any seasonal variation in terms of need. Nor an increase in need after air travel.

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