hunch....

 

An obese patient was referred down south for shortness of breath. Patient was found out to have elevated cardiac enzyme and referred to us to rule out myocarditis.

The patient had arrived hours later. He appeared to be severely obese and dyspneic even with oxygen use.

Upon examination, he was noted with mild wheezing and I had ordered a series of examination. A quick bed-side sonography was done and it was non-conclusive of any disease. An inhalation was ordered while waiting for the reconfirmation of cardiac enzyme. Patient was stable on oxygen supplement despite of hypoxia state shown on the monitor.

It was a routine workup however I was uneasy with his state as he had been inpatient for 2 days down south.

I had done a good history taking and found out that he had been a carpenter for his life and on and off attack of wheezing was noted with no major admission history.

The diagnosis of myocarditis was however not my primary diagnosis. I decided to do a CT scan as the mismatch of symptom of shortness was breath versus whatever test we had done.

The CT scan was ordered once his renal function test was out. He had multiple clot in his pulmonary vessel.

I had explained the test to the patient and his daughter and I was surprised that they were not unfamiliar with the disease. A further digging had found out that the patient’s son had pulmonary embolism at a very young age (14-15 years old). He was referred up to National Taiwan University Hospital and a genetic was done and found out that he had a specific gene that causing PE at a very young age. The pediatrician had advised everyone in the family to undergone the genetic test however no one bother.

A thorough history my ass….I grumbled to myself. You don’t ask they don’t answer. We had always asked family history about seniors in the family but not youngling.

The strange part was nothing suggestive of PE despite of the CT findings. The cardiac echo did not show right ventricle enlargement, the EKG12L was normal and the only hint was the mismatch of clinical findings. A few of my colleague had asked me why did I suspected the patient had PE and I told them that clinically I couldn’t get a diagnosis which can explained the pt’s SOB.

Well, a clear example that AI won’t be replacing this medical job in the near future….sometimes is just a hunch that lead to a diagnosis….