Ashley Billing -  Everything Is Not As It Seems


I expected there to be more pressure, considering there were only three of us, for my third visit to the male general medicine ward. I anxiously entered the hospital praying for a nice facilitator. We were assigned to an elderly Afro-Caribbean male with thin extremities, a distended abdomen, and scleral icterus. My mind immediately assumed he most likely had a liver problem. Therefore, when I took his history I directed my questions towards liver complications. "Do you drink alcohol? Do you do recreational drugs? Are you sexually active? If so, how many partners and do you use protection? Has this abdominal distension ever happened before?" While I understand these are not the most comfortable of questions, I attempted to gradually ease into the topic. I let him know that what he said would be kept confidential and I wanted him to feel comfortable.

However, judging by the rolling eyes, huffing breath, and rushed responses it was easy to tell that he was quickly getting irritated when I attempted to delve deeper into some of these areas. So I reassured him that my questions were only to help diagnose him in order to properly treat him. He had been an alcoholic for 15 years, particularly rum, and was sexually active with 2 women with whom he failed to use protection. He also smoked a pack of cigarettes a day for 15 years. He had edema, which started right before Carnival and had no prior history of similar episodes. Therefore, after taking a history I was convinced that liver damage was the cause of his presenting symptoms.

Upon physical examination, it was the first time I ever actually felt a fluid wave when tapping upon a patient's abdomen. So much fluid had collected in his body that upon auscultation and palpation, the stethoscope and my hand imprint were prominently engraved upon him. I tried to refrain from appearing taken aback. When measuring his liver span I also had to hide my worried concern when reporting that it was only 3 cm. All the evidence was pointing towards liver cirrhosis.

Once the history and physical examination were completed, we as a team regrouped outside with the physician to discuss our findings. This was the part I was worried about, because I was afraid of being drilled with questions and not knowing the answers. However, it was also my opportunity to shine. I was able to apply my knowledge of liver and biliary tract pathophysiology to determine that this patient did not have edema due to liver complications.

He failed to have coagulopathy due to decreased synthesis of clotting factors, gynecomastia, or spider angiomas due to buildup of estrogen, or mental status changes from increased serum ammonia.

Therefore, liver cirrhosis from alcohol seemed less likely. So as a group we discussed other potential causes of generalized edema. This allowed me to truly reflect on all we have learned and start making vital connections between diseases. Having a facilitator who was willing to teach, was instrumental in guiding us through the diagnostic process. She was able to help us navigate and differentiate between diseases, and helped us understand that a first impression is not always correct.

I also realized the importance of making the patient feel comfortable. I needed to remember to take the time to actually get to know them before diving into sensitive topics. A patient's name isn't just part of a chart. I had asked sensitive questions in an attempt to determine his underlying problem. Had I reduced the quantity of my direct questions and allowed him to talk more, I would have saved time and come to the correct diagnosis, anyway.

With all this said, this patient had a nephrotic syndrome affecting his kidneys. There was no problem with his liver despite drinking alcohol for 15 years, smoking, and having unprotected sexual relations with two different women. Patients cannot be judged based solely on their past.


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