Sunday, July 20, 2008

A smug smile

You might have seen doctors having a smug smile on their face while they look at the investigation results. The patient sitting opposite may think that the Doc is going to tell them some good news. The patient may expect the doctor to tell that the result is negative or the illness is cured. But most often it is the opposite.

Such smile comes on a doctor's face when the diagnosis he thought of is proved by the test result. The smile becomes bigger if some other doctor or doctors had missed the diagnosis.

I also had smiled like that many times especially early in my practise.Now a days I smile only if the result meant it is a curable or treatable condition.

Today I had a reason to show my smug smile.

She is a 65-year-old woman. She was admitted one year ago for altered behaviour and drowsiness following an episode of severe gastro-enteritis [diarrhea and vomiting]. Lab tests showed her Sodium level was well below normal. This was attributed to lose of salt due to vomiting and diarrhea. She was re-hydrated with sodium containing fluids and she recovered well.

I did not see her till last week when she was admitted for extreme tiredness,lack of appetite and vomiting. Her son told me that after last year's admission, she was not keeping good health. She needed frequent hospitalisation for various ailments.

When I examined her, she looked pale and swollen up. She was not listening to me properly and was very lethargic. Her sodium was again low, but other routine tests were normal. I did a Thyroid function study suspecting low level of hormone production from thyroid gland. The result showed I was right, but surprisingly her thyroid stimulating hormone which is produced by the pituitary gland was also low. This meant she is having Central Hypothyroidism and there is something wrong in the pituitary gland. When I did a series of other hormonal tests to evaluate pituitary function the results were equivocal[not helpful to reach a diagnosis].

So finally I ordered an MRI Scan of the pituitary gland.It was while reading that MRI Scan report that I broke into a smug smile.It showed an empty sella meaning pituitary gland is not visualised as it had shrunk in size.

As there is no tumour or injury visible in MRI, it meant that this is not a life threatening problem. She needs only replacement of hormones that is deficient. So I could smile liberally.
I gave the prescription for hormone replacement tablets. I also gave a reference letter to an Endocrinologist in the near by City so that a second expert opinion can be taken.

Many times I have got excited at the possibility of rare and exotic diagnosis.But immediately I try to curtail my excitement and try to think about it in the patients view point.
For this cute old lady the smile meant good news but for many others the news wont be good.

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