Annoying Little B!t@#

Initially appeared on doktorko.com on 3/18/2006.

It was eleven in the evening and i was on night float.  I was asked to see an elderly lady with dialysis-dependent kidney disease who had had diarrhea and vomiting for a week, missed dialysis a few days ago, and had shortness of breath.

The biggest issue was the dyspnea.  The easiest thing to do would be to call it fluid overload from not being dialyzed on time.  The chest x-ray showed "congestive heart failure" and the BNP was over 1000.

But of course, i'm not here to make the easy diagnosis.  I'm here to THINK.

So i go to the bedside and start obtaining a history (she had ischemic heart disease and hypertension - among other things) and asking about things like dry weight.  The nurse comes in, does whatever nursely things she usually does, and gives me a slightly disdainful look.  Unfazed (if a little boggled), i continue with my interrogation.

A few minutes later, i'm at the nurses' station thinking aloud.  I ask if they've weighed her.  She says - nonchalantly, as if it didn't matter - that they haven't.  I make a comment that it's a little hard to be fluid overloaded if you've lost ten pounds in the past week.  Then, a little exasperated, she shoots out: "It's OBVIOUS that she's fluid overloaded - her legs are swollen up, her x-ray was read as CHF, she missed dialysis this saturday, and her BNP is high.  SHE NEEDS DIALYSIS," and goes about her work, smug in the knowledge that she knows so much more than the idiot resident. 

Well -

1. in the first place, she was not severely short of breath.
2. she had had no orthopnea, PND, JVD, or hepatojugular reflux. In fact, clinically she was dry.
3. her legs had always been swollen because she's had vein stripping on the left and a fistula on the right.
4. the x-ray was "read" as CHF, but it certainly didn't look like it (i peeked).
5. somebody who's been pooping and puking excessively for a week with poor PO intake wouldn't really have any exogenous sources of excess fluid that would need to be dialyzed .
6. BNP is essentially useless if you've got ESRD.

So i do what i do best: gather all the data, synthesize a diagnosis (dehydration from one weeks' worth of AGE-type symptoms; shortness of breath secondary to pulmonary edema from diastolic dysfunction caused by ischemic heart disease and uncontrolled hypertension - and not "fluid overload" like the simpleton suggested) and give the appropriate treatment (unload the heart with blood pressure control and give gentle hydration).

I suppose i SHOULD have tried to broaden the scope of her thinking; essentially to EDUCATE her, but i had more important things to do (like eat, and read my Stephen King book).  Thoroughly p!$$3d off, i just decided to let her wallow in her simple-mindedness.  I doubt that she would have understood (or even listened to) my reasoning anyway. 

The ignorant are always completely sure of what they're doing.