Archive for August, 2009

Big Liver and Dropping the ball

Big liver vs little liver

Sigh, it has been a while, turns out that the outpatient world is not only a lot more boring than the inpatient world, it also makes me a lot more lazy. So I haven’t really had that many clinically interesting stories to put on this page, lots of other cool cases for me and my case logs, but nothing too crazy. Although…last week one of my patient’s fathers wanted to know how he should go about asking me out. This is of course after we got done talking about the sleeping arrangement between the patient’s mother and him. So yeah, you can guess how that well that worked out for him.

Ok, about this week’s case. This is actually a story about how I messed up. So, I was on call last night. A patient had been admitted to the floor with uncontrolled type one Diabetes. Only he came in because he was having diffuse abdominal pain. So, during my evaluation of him, I did what I thought to be a pretty good abdominal exam, as well as a pretty good general exam. He did have hypo-active bowel sounds. He was more tender on the left quadrant, and a little on the right upper. But he was also really tense and anticipating the pain. I did NOT feel an enlarged liver though I should have done a better job of palpating for one, and I backed off on palpating his spleen because again he was really tender on the left side, I didn’t push it. He looked like he was a little bit ichteric (yellow eyes) but I attributed that to his coloring.

I concluded from my exam that his abdominal pain was from his acidodic state and his mild to moderate ketotic state. I was going to re-evaluate when his evening labs came back. So, I went to bed, checked his labs a little after midnight, they were not back yet, so I figured I would just check them later. I had a couple of calls overnight, nothing to do with him, he was stable, and I forgot about the labs till 6am.  Well, then my senior had checked them around 1:30 in the morning, his liver enzymes were super elevated so she went back and re-did the abdominal exam.  Longer story a little bit shorter, she found his liver to be enlarged, and sent him down for an ultrasound and did a hepatitis panel. I just now checked on the results of the ultrasound and hepatitis panel, and though everything else was fine, the ultrasound showed mild to moderate enlargement of the liver.

So, aside from the fact that I missed a crucial aspect of my exam, an exam that I can actually feel comfortable saying I typically do very well, I let my laziness and complacency put a patient in potential danger. I can’t believe I missed that and I let that happen. And so early in my career. Well, I am glad this happened now, cause I sure as hell won’t let it happen again, and I am glad that my senior had my patient’s back when I dropped the ball.

This is a lesson I will not forget.


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