How does a doctor think?

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22 Φεβ 2014 (πριν από 3 χρόνια και 5 μήνες)

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Dr. Rick Lloyd
-

August 27, 2012

Pediatrics
, Palo Alto Medical Foundation


How does a doctor think?

3 example cases:



6
-
month
-
old boy

o

He comes in with a low
-
grade, tactile fever (He is warm to the touch) and
a cough. His breathing did not seem troubled until the morning of the visit.

o

The doctor performs an examination after listening to the patient’s history
(obtained through the mother
)

o

Upon examination, the child’s throat is slightly red, and the ear drums are
fine.

o

The boy has abdominal breathing, with retractions during each breath.



Retractions occur when the muscles between the ribs pull inward.
This is more common in babies becau
se they have more cartilage.

o

The patient’s blood oxygen content is 98%, which is normal.

o

During a routine examination of the chest and abdomen, the doctor notices
raucous sounds and wheezing during each breath, especially in the right
middle lobe.



Means

that the muscles around the lungs are restricting the airways



This makes the doctor confident that the patient has pneumonia



Chest x
-
ray is deemed unnecessary

o

To treat the pneumonia, the patient is given an antibiotic and a
broncodilator.



The bronodilat
or helps relax the muscles and open the airways

o

In a week, the patient is better.



6
-
month
-
old
-
boy, with similar symptoms

o

Low
-
grade

fever to the touch, a cough, red throat, runny nose,
sounds in
the chest
, retractions

o

97% oxygen levels, which is a bit low

o

T
his patient is sicker than the first patient



The patient gets a chest x
-
ray, and there is consolidation in the
right middle lobe, indicating a viral pneumonia

o

This patient is given the same treatment as the first, a combination of the
antibiotic and the
broncodilator.

o

In a week, the patient is not feeling better. In fact, he is feeling slightly
worse. The x
-
ray is unchanged.

o

The doctor asks if the boy choked on anything, because the right middle
lobe is the most likely placed for something choked on or
inhaled to go.
However, the family answers no.

o

Next, the doctor prescribes an inhaled steroid.



The breathing is still labored, and the oxygen levels in the blood
are the same.

o

A CAT scan could be done, but the radiation levels would be much higher
that
those of an x
-
ray



Radiation is not cumulative, but the more a person receives, the
more likely it is to affect them

o

Another possibility is cystic fibrosis



A test is done (by measuring the sodium content in the patient’s
sweat) and the results come back neg
ative

o

Three other possibilities:



Right Middle Low syndrome



An abnormally placed artery in that area that is compressing the
bronchus



A lymph node is obstructing the bronchus

o

A bronchoscopy is done



The stem of an apple is discovered in the bronchus



14 year
-
old girl

o

Comes in with a swollen right knee



Has been swelling on an off for a couple of months



She is a catcher in softball, so she assumed that the swelling was
the result of a softball
-
related injury



However, there was no specific injury

o

She has not tra
veled out of the country, doesn’t report any stiffness in the
morning, and the doctor doesn’t hear a murmur in her heart

o

After listening to the patient’s history and listening to the family talk, the
doctor can ask more directed questions:



Do you have a fa
mily history of arthritis?



The mother had arthritis



Had the family been on hikes?



Yes



Did she have a tick bite?



No, not that they knew of



Did she have a rash?



No

o

People developing lupus arthritis get a distinctive,
butterfly
-
shaped rash

o

People with Lyme
disease develop a target
-
shaped
rash on their backs

o

Lyme disease was still a possibility because only half or people with the
disease recall having been bitten by a tick or having a rash



A blood test was done for Lyme disease, but the results were
negative



However, Lyme disease tests are not very accurate

o

The antigen protein tested for is often present in the
body under normal circumstances



Blood count was normal, but she was slightly anemic

o

A Sedimentation rate test was done, which is very accurate



The res
ult was 50, which is high



Indicates that the infection was more serious than it
appeared

o

There was a possibility of pus in the knee



She was tested for septic arthritis, a bacterial infection of the knee



Test was negative

o

Juvenile rheumatoid arthritis was a

possibility



The rheumatologist looked for oral or nasal ulcers, which she
didn’t have



She was put on the same medication her mother used for arthritis

o

This past Saturday, she came in with a rash in her mouth



The doctor and rheumatologist agreed that the
knee problem was
something more serious, having to do with the rash in her mouth

o

A culture of the rash, a sedimentation rate, and blood count were done



Sedimentation rate and blood count were normal


Why should you be a doctor?

o

Being a doctor is hard work,

but rewarding.

o

The reason for becoming a doctor is the desire to be of service and to make
a
difference in other people’s lives.