A straightforward ear infection, and the work up of vasculitis

Tell me how can I choose?

The labs will come slowly as news

I won’t be so brash

As to diagnose a rash

That shows as many a bruise. 

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Friday morning arrived and the sweetness of yesterday, with 15 patients before lunch and no computer, lingered.
The first patient of the day, an adult with ear infections, gave me permission to write more than I have. Most people who come to the doc with cold symptoms expect an antibiotic, though studies show a good explanation of why an antibiotic runs more risks than no treatment satisfies the majority. Still the explanation takes more time than writing the prescription.
Current wisdom holds that a physician can justify an antibiotic in the presence of fever, more than 10 days of symptoms, or “second sickening,” where a patient started to improve and then worsens.
I see adults with ear infections so rarely, and I spend so much time gently coaxing patients away from antibiotics, that finding not one, but two bright red ear drums in a single patient gave a great start to the day.

The second patient came in with a rash.  I said, “I write a blog.  I won’t say gender, age, name or diagnosis, but I’d like to write about vasculitis and the steps a doctor has to go through,” and the patient agreed.

When I look at a rash, I want to know if it blanches, that is, loses its color under pressure.  And I want to know if I can feel it.  Tiny bruises, petechiae, that cannot be felt, herald serious disease.  I went to the Internet to find what labs to run.  In the three years since I last saw a case of vasculitis, the work-up has changed, but not much.  I printed off a page, handed it to my nurse, gave her a thousand apologies, and asked her to enter the orders into the Electronic Medical Record.

Then I settled in to read about treatment.  We always like to have a firm diagnosis before we start administering medication, and the firm diagnosis can’t happen until the lab results come back.  A lot of those probably won’t arrive before Thanksgiving.  After that, urgency of treatment depends on symptoms.

It took the nurse as long to enter the long list of lab tests into the computer as it did for me to read the monograph.  I thanked her profusely.

I read the authoritative monograph, and shook my head when it said that 72% of cases of vasculitis will not be conclusively diagnosed.

Last century, at another clinic in another city, a young man came in with a sore throat in the middle of a strep epidemic.  I love a slam-dunk diagnosis I can do something about, but as I exited the room, he asked, “What’s this rash?  I was just sitting here and I noticed it,”  and he pointed at his ankle.  With outside temps hovering in the negative double digits, he wore no socks.  Those tiny purple bruises on his lower legs prompted an investigation leading to a hospitalization, and uncovered a heartbreaking story of drama, irony, hunger, homelessness, love, betrayal, and chemical dependency.

Some things don’t show up on a lab test.






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