Friday, May 7, 2010

Diagnosis - Pregnant and Pained -

Even sitting quietly in the hospital bed, the young woman looked out of breath. The muscles of her neck were pulled tight, and she lifted her shoulders as she inhaled, as if simply taking in air required work. According to the chart that Dr. Roxanne Wadia had glanced through, the patient was five months pregnant. But her arms and legs were thin and wasted-looking, and she had only a tiny hint of the expected baby bump. Her eyes were sunken, and her skin was sallow. Looking at her new patient, Wadia, a resident in her second year of training at Tufts Medical Center in Boston, felt her own heart quicken. The patient was clearly sick. The doctor gave her patient oxygen and then sat down to take a history.

The troubles started when she became pregnant, the patient told her. She had barely missed her period when she started throwing up. She was hungry, but even the thought of food made her stomach heave. She could hardly get herself out of bed. Her OB-GYN gave her all kinds of medicines, but none of them worked. Finally, she had lost so much weight that her doctor put her on intravenous feedings. She put the weight back on and then a little more, but she still felt sick. "Even now," she said, "I can hardly eat a thing without vomiting."

But that wasn't why she was here now, she told the young doctor. No sooner had she got the vomiting under control than she developed a terrible cough. She didn't have a fever, but the racking cough made her body ache all over. Her husband said it sounded as if she were coughing up a lung. Her OB said it was probably a virus. Whatever it was, it didn't go away. Over the next several days, the cough became almost constant, and with every cough came pain — a pain that felt like a gigantic claw squeezing her chest and back. Finally her husband called the OB, who sent her to the hospital. After much discussion about the risks of radiation during pregnancy, a chest X-ray was done. The lower third of her right lung was filled with fluffy white where it should appear almost solid black. Pneumonia, they told her. She was admitted to her local hospital in Cape Cod, and she started on antibiotics. But she still didn't get better. The next day her fever spiked to 101.5. The day after that she started coughing up blood. The doctors switched to other antibiotics. When that didn't help, they sent her to Boston.

On exam, the patient had no fever, but her heart was beating rapidly. Her breathing slowed somewhat after she was given oxygen but was still faster than expected. When Wadia put her stethoscope on the patient's back to listen to her breath, she heard another sound as well — a sound like crisp paper being crumpled. But it was distant, as if it were in another room. The rest of the exam was unremarkable.

Wadia settled down with the stack of papers that traveled with the patient from the last hospital. She was impressed with the doctors' thoughtful approach to this complicated patient. The patient had been admitted with what looked like a run-of-the-mill pneumonia caused by a run-of-the-mill bacterium. When the infection didn't respond to antibiotics, they considered other possibilities. Could she have a pulmonary embolus — a clot from somewhere in the body that traveled and became wedged in the arteries of her lungs? That could certainly cause a cough and shortness of breath. It could even cause the bloody sputum and the fever. And a pregnant woman was at higher risk for a pulmonary embolism because the hormones of pregnancy made the blood thicker and more prone to clot. Spending so much time in bed because of nausea also increased her risk of a clot. Her doctors had looked in several different ways but hadn't seen one.

Was the problem related to her heart? That could cause the cough, the shortness of breath and the crinkly noise in her chest. This patient had no history of heart abnormality, but sometimes a new problem can develop or an old problem can be unmasked during pregnancy. But an echocardiogram, an ultrasound of the heart, was normal. If it wasn't a clot or a problem with her heart, maybe itwas an infection, but not one caused by a common bug. Could it be tuberculosis or H.I.V.? Could it be a fungus? None of those would respond to the antibiotics she'd been given. At a bigger hospital, like Tufts, doctors would be able to put a camera, known as a bronchoscope, into her lungs to look for evidence of some of the more unusual causes of pneumonia.

Late in the evening Roxanne Wadia called Dr. Geraldine Finlay, the attending physician in charge of this patient's care and the doctor who would perform the "bronch." Finlay, a pulmonologist, listened as the resident laid out the patient's story. When Finlay heard that the young woman had gotten worse on antibiotics and begun coughing up blood, she immediately suspected that this wasn't an infection but a blood clot in the lungs — a pulmonary embolus.

A common error in medicine is the assumption that tests provide definitive answers. In the math and science classes doctors take leading up to medical school, we work through a problem, come up with an answer and then check the back of the book to see if we got it right. We treat medical tests as if they provide these back-of-the-book answers. They don't. A medical test is simply another clue in the puzzle.

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