Getting back to basics…Medicine 101
By Paul Goldfinger, MD, FACC. Dean of the Blogfinger Off-Shore School of Medicine in Ocean Grove, NJ.
She was a tall thin blond, 22 years old, from Germany. She had long graceful legs and she was a good looker. But she was more than just that; she was an international elite high jumper and she was exhausted. Beside muscle weakness, she had leg cramps and she had passed out a few times.
I admitted her to the internal medicine teaching service at Mt. Sinai Hospital, located on the upper east side of Manhattan, facing Central Park. The year was 1967 and I, a first year medical resident, was struggling to come up with a diagnosis.
She seemed perfectly healthy. Her history was unrevealing, and her physical examination was unremarkable. Doctors like to say “unremarkable” for normal, but she was anything but unremarkable. She denied taking any drugs, being on a crazy diet or vomiting to lose weight. We ran tests on her, and there was only one salient abnormality: her blood potassium level was very low. In other words, she was hypokalemic.
The second year resident, the chief resident, and the attending physician could not figure out the cause of her electrolyte disorder. “Electrolyte” refers to the minerals in the blood such as sodium, potassium, chloride and calcium. We ruled out kidney disease and metabolic problems.
Dr. Solomon Berson, the Chief of the Department of Medicine, said that he would order an experimental serum insulin level from his lab—a test that would eventually win the Nobel Prize in Medicine. But that didn’t help either.
Finally I decided to go back to basics and take another history. It’s like those cop shows when they keep interrogating the suspect until something squeaks out to solve the case. In the 1960’s, a great deal of emphasis was placed on talking to patients, because our testing methods were so primitive compared to today’s.
It seemed that I would have to lower the talking bar for this high jumper. So I tried another detailed history. We discussed her life and her habits. Finally the truth popped out: she was a secret user of thiazide diuretics. It wasn’t clear why she was doing that. She didn’t know that diuretics cause your body to be depleted of potassium. We took away the diuretics, and she was cured.
Next stop was the psychiatry department. Meanwhile I got a case report out of it in the Mt. Sinai Journal of Medicine plus a bit of notoriety at “Sinai” which lasted about two days. It was the first time a published medical report contained a serum insulin level.
History taking is becoming a lost art. Electronic medical records encourage doctors to use checklists and computers, and often the history is obtained by a medical assistant or “physician extender.”
There is an old saying in the profession: “Listen to the patient; he is telling you the diagnosis.” The great Sir William Osler, one of the founders of the Johns Hopkins Hospital, is credited with those words of wisdom.
LITTLE WILLIE JOHN:
Speaking of Osler, I interviewed at Johns Hopkins in Baltimore for a position on their famous “Osler Service.” This was an internship where interns were on call for 365 nights in a row. But I wanted New York and I wanted some sleep once in a while, so I chose Mt. Sinai.
It was the best choice—I stayed there for 5 years–always with a pen and paper. And we also learned now to conduct a proper physical exam and how to use those stethoscopes around our necks.
Compliments on making a diagnosis that left even the renowned Dr. Berson scratching his head. “It takes a clinician. . .”
Good basic questions and a search pays off
great job, I can appreciate it as I have an electrolyte imbalance regarding sodium.
Fascinating case!!
NICE GOING PAUL!