Wednesday, October 17, 2007

i be a doctor!

One thing I love about the internet is that you can be anybody you want to be. I don’t mean like the 58 year-old perverts that pretend to be teenagers “just looking for someone to talk to, that might like me for who I am” (ironic, eh?) For those guys, I laugh my ass off when they show up in Denny’s parking lot with a case of Viagra and case of condoms, big jar of body lotion, rope, and video equipment, get busted, and say, “I was just showing up to tell her how dangerous it is to meet people on the internet.” “Tell her”? More like, “Show her,” eh Perv? I know a lot of guys in prison – mean guys – piss-your-pants-when-they-walk-in-the-bar-and-glance-your-way guys. All Perv gets there is, “You better lather up bobo good in your mouth, so it rams more easily into your ass.” Ah, poor baby!

So anyway, I got all these sites that somehow or another – for the life of me I don’t know how or why think I am a doctor! I mean, go figure, eh? Me? A doctor? I went to law school. Don’t need no job where I have to put my finger in someone’s ass. I’d rather clean out their wallet without touching their privates, thank you very much.

One site that thinks I am a doc is Every once in a while I get these case studies e’d to me. They call them … wait for it … “eMedicine Case Studies.” Now there’s a large dose of marketing angle all bundled up into a catchy name.

So this latest one is called, “A Toddler With Fever and Abdominal Tenderness.” I get pics and facts, and have to guess what the problem is. I get a hint, too! A hint? WTF? Doctors get hints? Can you imagine me in my law office, “Sounds like you have a big issue here. You may have a case. Can you give me a hint as to what kind?” Must be nice to work in a profession with hints …

So we get three pics, X-Rays it seems to me, an untrained-yet-apparently-licensed doctor. Let’s look at the first one.

Ah, we have the word, “Upright” and the letter, “R” on it. Must be clues. Tucked away on the upper-right side (you may need to click the pic to see it larger), it reads, “Abdomen with Upright.” Hmmm … abdomen with upright. “Upright” must be a thing. Like, “Abdomen with Dog.” What’s an “upright”? Maybe it’s a tool of some kind, a doctor tool. This is interesting! What’s this?!? Below the tool name it reads, “8/31/2005.” This X-Ray is old! How can I do my job with old information? No wonder MedMal rates are so high. They use information that is over two years old to diagnose something in my in-box today! I am appalled! I might resign from the Medical Board! Send a nasty letter to the Chief Whatever They Call Him or Her at the hospital. It is to laugh. Fine. You know what? I will persevere in the face of adversity – in the face of incompetency – and solve this case. Let’s look closer at that X-Ray thingey.

Seems kinda hollow up top. That’s weird. Might be a problem. Better write that down. “Patient presents hollow top as she/he holds Upright tool.” Making progress.

The kid seems all kinda milky white in the lower half. Marked difference from the hollow top. “Patient presents half-full lactose container in lower half as he holds Upright tool.” I like being a doctor! I’m like really good at it.

Now, in the milky stuff (I’ll try to keep the technical jargon to a minimum. You’re welcome.) there seems to be holes, and then something pointing at them. See it? Left to right. Holes. What could the holes be? Think outside the box, Dr. Clyde. Think, think, think. Maybe they are not holes at all! Ah ha! Maybe they are not holes at all! Maybe, now follow me here, maybe they are the opposite of holes! Like something Stephen Hawking would say about something in space: Maybe the holes are actually the substance! They are like balls and that pointy thing is a cue stick! I GOT IT! The kid is a problem masturbator and he’s playing pocket pool!

Ta da! Case solved. I am soooo good at this doctor thing.

Wait. Can’t rush into a diagnosis. Let’s count the horizontal thingeys that look like spare ribs. Well, I see … ok … one minute. OK, well, the kid could still be playing 9-ball, but if he’s that into pocket pool his dick is pretty high up there. Whoa, Nellie, this boy must be hung like a horse!

We need more data. Let’s go to the 2d pic.

Looks like the milk spilt. Just can’t get good techs these days. Amazing. There’s that pool stick again. Look at those things standing up at the bottom, running the full length of the X-Ray. “Patient presents sticky things,” no wait, “stick-like th—“ snap Damn! Pencil broke. One sec. OK. “Patient presents a series of apparent hard substrate thingeys that resemble rowing boat oars along the entire length of X-Ray. NOTE TO STAFF: Be sure the spilt milk is cleaned up. It’ll stick to somebody’s ass in a day or two and that is all I need is to stick my finger into a sticky ass.”

What else can we learn? Well, if you turn it 90 degrees CCW, it looks like a clown with a stick in his eye. “Note to self, get milk and bread on the way home.”

OK, that’s all here. Last pic coming up.

What the hell is that? Looks like something you’d see in war room of a 3d world country as it is planning an invasion of the neighboring country’s rice paddies. Must be misfiled. Let’s move onto the facts they give us.

“BACKGROUND” (That’s a good way to start. Maybe this will explain how we got the rice paddy picture in with our medical files.)

A 14-month-old boy is brought to the emergency department (ED) (ED? Erectile Dysfunction? You see, they’re thinking a “pocket pool” diagnosis, too) by his parents for an evaluation of persistent fever, vomiting, and diarrhea that has lasted for 3 days. (The kid’s barely a year old, ralphing for three days, and now you bring him in? Where’s Social Services? Do that hall? 3d door on right? Thank you.) The mother states that the child was examined by his pediatrician 2 days before (likely story. CYA. lying bitch.) this presentation for a “viral illness“; however, the child has appeared increasingly ill since then(I’m sure he has, ma’am. Let’s take a look. Oh, I think those folks with the clip boards and hemorrhoids want to talk with you.). He has become irritable, and he has been minimally active and feeding poorly. He has had a normal stool output and appearance, as well as normal urination frequency. The parents deny (deny, deny, deny, white trash) observing a runny nose or any coughing, wheezing, or stridor in the patient. The child lives at home with his parents, he is not in day care, and he has had no contact with people who are sick. (More like, “No contact with the outside world so we can watch him puke for three days.)

On physical examination, the boy is crying, fussy, and poorly consoled (that’s because he doesn’t have the speech skills to say, “get me the fuck out of that house! They’re crazy). His vital signs include a rectal temperature of 101°F (38.33°C) (you see, docs are all “rectal” this and “rectal” that – no thank you), a respiratory rate of 32 breaths/min, a blood pressure of 98/56 mm Hg, and a heart rate of 168 bpm. His oxygen saturation is 100% while he is breathing room air (as opposed to the closet air he breathes when Jim-Bob and Thelma-Lou go bowling?). The patient’s weight is 22 lb (10 kg). Palpation reveals diffuse abdominal tenderness without rigidity or guarding. The patient has diffusely hypoactive bowel sounds (I’m telling you, that ain’t no bowels – it’s a pool table). His stool is negative for occult blood. The rest of the physical findings are otherwise unremarkable (except for the fact that his 14-month old dick is longer than his left leg).

Conventional abdominal radiography and computed tomography (CT) scanning are performed (see Images (yeah, thanks, did it. including the misfiled one.)). The laboratory investigation reveals the following results: white blood cell (WBC) count, 19.4 × 109/L, with a predominance of neutrophils; hemoglobin, 8.4 g/dL; hematocrit, 26.6%; platelets, 310 × 109/L; sodium, 136 mmol/L; potassium, 3.8 mmol/L; chlorine, 105 mmol/L; CO2, 20 mmol/L; blood urea nitrogen (BUN), 6 mmol/L; creatinine, 17.7 µmol/L (0.2 mg/dL); and glucose, 4.1 mmol/L (73 mg/dL). The urinalysis shows trace ketones, but the results are otherwise normal. (I learned a long time ago that if Word underlines something in red, it means that it isn’t important. About half this paragraph is underlined – so just ignore it.)

What is the diagnosis? (Problem masturbator with abnormally large dick.)

“HINT” (Here we go. The cheating profession.)
The patient’s symptoms developed approximately 2 days after the mother dropped a box of pins on the carpet at home. (Social Services!!!)

A “hint”? You call that a “hint”? Why not give a map to the treasure with a big red X on it, a geo-thing-a-ma-bob that tells you where you want to go, and a fist full of McDonald’s coupons?

“ANSWER” (Well, this oughta be incredibly reduncant. See “hint.”)
Appendiceal perforation by a foreign body (a pin) (oh!): A foreign body was easily apparent on conventional abdominal radiographs in the right lower quadrant (it’s a pocket-pool cue stick, thank you very much). CT scanning (I didn’t see no CT Scan. They hiding information?) of the abdomen and pelvis revealed a radiopaque pin and a multiloculated fluid collection at the level of the L5 vertebra. The prominent bowel loops superior to the pin likely represented focal ileus. (Those last two sentences are all underlined in red by Word – meaningless.)

Ingestion of foreign bodies is relatively common among pediatric patients, who account for approximately 80% of cases. Most objects pass spontaneously; only 1% of all foreign body ingestions require surgical intervention. Among adults, foreign body ingestions most frequently occur in patients with psychiatric disease or in those with a potential secondary gain. (That’s a good story.)

Management of cases of foreign body ingestion depends on the type of object ingested. (Duh!) The objects most commonly ingested are coins, buttons, parts of small toys, pins and thumbtacks, and disk-shaped batteries. For known ingestion of nontoxic, smooth, or small objects, management is conservative because approximately 80-90% of these foreign bodies spontaneously pass though the GI tract without causing harm.

Initial radiographic localization and serial abdominal radiography should be performed every 24-48 hours (and people wonder why insurance rates are so high – Swallowing a pin: $2.00 a dozen. Two X-Rays: $795.00. Taking a picture of my shit as it flows through my system every one to two days: Priceless!) to monitor the progression of the object until it is passed in stool. Foreign bodies may lodge at any site in the GI tract, but most often they lodge at anatomic sphincters (sounds like something that would invade Earth), sites of previous surgery, or areas of narrowing or acute angulation, where they tend to cause obstruction or perforation. The esophagus has several sites of potential obstruction (yadda, yadda, yadda – does this ever end?), and perforation at these sites is a particular concern because the rates of related morbidity and mortality are high. The complications of foreign bodies in the esophagus include mediastinitis, lung abscess, pneumothorax, and pericarditis. (red, red, red) Approximately 90% of foreign bodies that reach the stomach pass through the remaining GI tract. Most smooth objects pass within the normal bowel transit time.

(OMG, Shut up already!) Because of the high risk of intestinal perforation, urgent intervention is indicated for all patients who have ingested a long, thin, sharp, or stiff foreign body that fails to progress through (oh wait, I can shut them up! I forgot.)

So what did they do for the problem masturbator?

A laparotomy, drainage and excision of an intra-abdominal abscess, as well as an appendectomy and removal of the foreign body, were performed. The appendix was 4.3 cm, and a metallic pin was found piercing the bowel wall. The histology revealed acute serositis with fibrinopurulent exudates in the lumen and on the serosal surface of the appendix.

YOW! They took out the boy’s gizzard! Damn! And they got his Pocket-Pool Cue Stick, too! I always wondered what those things looked like. Neat.

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