Dr. Rick Lloyd
August 27, 2012
, Palo Alto Medical Foundation
How does a doctor think?
3 example cases:
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.
The doctor performs an examination after listening to the patient’s history
(obtained through the mother
Upon examination, the child’s throat is slightly red, and the ear drums are
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.
The patient’s blood oxygen content is 98%, which is normal.
During a routine examination of the chest and abdomen, the doctor notices
raucous sounds and wheezing during each breath, especially in the right
that the muscles around the lungs are restricting the airways
This makes the doctor confident that the patient has pneumonia
ray is deemed unnecessary
To treat the pneumonia, the patient is given an antibiotic and a
or helps relax the muscles and open the airways
In a week, the patient is better.
boy, with similar symptoms
fever to the touch, a cough, red throat, runny nose,
97% oxygen levels, which is a bit low
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
This patient is given the same treatment as the first, a combination of the
antibiotic and the
In a week, the patient is not feeling better. In fact, he is feeling slightly
worse. The x
ray is unchanged.
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.
Next, the doctor prescribes an inhaled steroid.
The breathing is still labored, and the oxygen levels in the blood
are the same.
A CAT scan could be done, but the radiation levels would be much higher
those of an x
Radiation is not cumulative, but the more a person receives, the
more likely it is to affect them
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
Three other possibilities:
Right Middle Low syndrome
An abnormally placed artery in that area that is compressing the
A lymph node is obstructing the bronchus
A bronchoscopy is done
The stem of an apple is discovered in the bronchus
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
However, there was no specific injury
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
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?
Did she have a tick bite?
No, not that they knew of
Did she have a rash?
People developing lupus arthritis get a distinctive,
People with Lyme
disease develop a target
rash on their backs
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
However, Lyme disease tests are not very accurate
The antigen protein tested for is often present in the
body under normal circumstances
Blood count was normal, but she was slightly anemic
A Sedimentation rate test was done, which is very accurate
ult was 50, which is high
Indicates that the infection was more serious than it
There was a possibility of pus in the knee
She was tested for septic arthritis, a bacterial infection of the knee
Test was negative
Juvenile rheumatoid arthritis was a
The rheumatologist looked for oral or nasal ulcers, which she
She was put on the same medication her mother used for arthritis
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
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?
Being a doctor is hard work,
The reason for becoming a doctor is the desire to be of service and to make
difference in other people’s lives.