Wednesday, July 13, 2016


I saw a guy for headaches recently. Nothing unusual in his story, but, since he'd never had them before, I ordered a brain MRI. I figured, like most of them do, it would come back normal.

I wasn't even close. It came back, not just abnormal, but weird. All kinds of odd changes. Nothing easy to point a finger at, like a stroke or brain tumor. But definitely not normal.

Like I always do in these cases, I called the neuroradiologist who read it, and discussed the case. He was pretty certain of the strange findings. We reviewed all the different causes, and none of them fit with his history.

Because of the unusual nature of the findings, I got a copy of the MRI and took it to another neuroradiologist for a 2nd opinion. She absolutely agreed with the first guy.

So, I was stuck with something weird, not easily explainable for his case. After hospital rounds the next night I went to the hospital library, and spent some time looking up the findings, what can cause them, how you work them up, etc. I had Mary bring him in, working him in over lunch to give me extra time to discuss the news with him and answer his questions.

He came in, and I took some time. I explained the findings, and what they might mean. I went over the steps to work them up further, including a spinal tap and labs. He and his wife sat in silence as I went over everything. Finally, I opened up the floor for questions.

Mr. Sternberg: "These abnormal findings, could they be caused by lymphoma?"

Dr. Grumpy: "You have lymphoma?"

Mr. Sternberg: "Had. About 10 years ago."

Dr. Grumpy: "How did they treat it?"

Mr. Sternberg: "I had chemotherapy, and they did radiation treatment on my whole body and head."

(Pause. I pick up the phone and call the neuroradiologist, who says that, yes, absolutely, the changes are typical for someone who's had radiation).

Dr. Grumpy: "Yes, they're likely from radiation. Why didn't you tell me you had lymphoma?"

Mr. Sternberg: "I didn't think it was important. By the way, my headaches are gone."

Today's lesson people: When the neurologist asks about your past medical history, lymphoma and brain radiation are things you want to mention.


MSGMD said...

So, was that a level 5 follow-up or a level 1?

Anonymous said...

Patient history aspect of the electronic health record business would be a benefit if it included this information, wouldn't it? Unfortunately, the numbskull drivel format has a way of obfuscating the important details, so one has to depend even more on that spidey-sense. Where does it come from, anyway? Well, something to put in that black bag that doctors carry around?

It's the old story about the patient and hypertension. The blood pressure medicine 'normalizes' readings, so 'no' there is no problem with blood pressure, and surely no problem with the over-the-counter decongestant, or on-line 'fat buster' and then we see the after-effects of the stroke.

clairesmum said...

I wonder if he really was thinking that the headaches were due to recurrence of lymphoma but had that superstitious "if I don't say it out loud it won't be real" attitude.

and a useful EHR might have helped.

Mage said...


Candy said...

My husband was asked if he had a family history of cancer. He said no. And when I reminded him of his 2 sisters. He said "but they're dead"

Spook, RN said...

Doc Grumpy,

Don't even get this ER nurse started! I can't tell you the amount of frustration I experience everytime I triage someone and try and get a medical history.

It is one thing for lil' ol' ladies who go "Oh, I have a heart problem and Dr. Heartguy says I should take this little white pill and a little brown pill twice a day."

QUITE another for otherwise active, cognizant adults! I've even started offering 'leading' questions i.e. "Do you have any heart/lung/kidney/stomach/bowel/bladder/brain disease? High blood pressure/stroke/heart attack? Ever been DIAGNOSED with ANYthing at all - from birth to now?" When that tactic doesn't work, I switch to "what medications do you take daily?"

I still get the ones who 'forget' that they had Cancer! An MI!

But even those are sometimes forgivable - as compared to the indignant "it should be in your records!" crowd. My feelings about this sub-species of patients/family members probably compares to your feelings of 'Artisinal' products...


Zed said...

Hilarious! It's reassuring to know that this can happen to a physician at any stage, not just medical students.

Unknown said...

Thinking is hard. And this does not bode well for our society.

Anonymous said...

The number of women who forget they had a Hysterectomy (when coming in for abdominal pain) is Astounding!

Sara said...

Wow, the guy was forgetful, but radiation changes are quite typical in their appearance and it sounds quite weird to me that neither you, nor the neuroradiologists even thought about this...

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