Always listen to patient carefully! Two clinical case stories by a leading liver expert. 10
Renowned Professor of Medicine at Harvard Medical School tells a great diagnostic story of his patient with intestinal bleeding. A second story how a tick bite infection cured another patient’s Hepatitis C. You are a prominent liver expert and professor at Harvard Medical School. Is there a clinical case, a story of a patient from your practice, that can illustrate some of the topics that we discussed today? Dr. Anton Titov, MD. There are so many interesting stories to tell about patients. One of the key things in medicine is for us to be very very good listeners. To take a very good history. We have the tendency to interrupt, because we are formulating a differential diagnosis. We are rushed for time. Dr. Sanjiv Chopra, MD. Patient is sitting there and has gastrointestinal bleeding and we have been consulted to maybe do endoscopy or colonoscopy. Patient is anemic. You can do a quick history, physical examination and then schedule the patient for colonoscopy or EGD Dr. Sanjiv Chopra, MD. Some years ago I got consulted – I was covering the gastroenterology service at that time as well – and we got consulted to see a patient for colonoscopy. He is 50-some years of age, he’s got mild iron deficiency and guaiac-positive stools. Dr. Sanjiv Chopra, MD. The student goes and sees the patient. The gastroenterology fellow went and saw the patient. Then they presented to me. Then I go and make rounds. I discover. They’ve told me this, that the patient also has hypercalcemia. Therefore endocrinology service is seeing him. The patient also has renal failure, so nephrology is also seeing him. It turns out these were very eminent consultants, who were seeing him. Dr. Sanjiv Chopra, MD. I go to see him and I am trying to figure out, where is he bleeding from? Dr. Anton Titov, MD. So I’m taking a detailed history. “Any abdominal pain? Any change in the color of your stools? Any constipation and what is the caliber of the stools? Any family history of colon cancer? Have you ever had a colonoscopy? Barium enema?” All of that is negative, negative, negative. Then I focus on the upper gastroenterology tract. So I ask him, “How’s your appetite? Any early satiety? Can you eat a full meal? What’s your favorite food? Sometimes I bring it in front of you will you be able to eat it?” “Yes, I’d be able to finish it.” Dr. Sanjiv Chopra, MD. I said to him, “Any heartburn?” – Now I’m thinking of esophagitis and he says, “Yeah, little bit.” I said, “What do you take for it?” – he said, “Nothing really.” Dr. Sanjiv Chopra, MD. I said, “Do you take any TUMS, Rolaids, Alka-seltzer?” He said, “Yeah, I take some TUMS” [calcium-based antacid] I said, “How many rolls?” he says, “Six rolls a day.” I said, “What?! That’s a lot of TUMS!” I said, “Do you drink milk?” He says, “Yeah I drink quite a bit of milk.” I said, “How much milk?” It is like two gallons of milk! Dr. Sanjiv Chopra, MD. I’m saying, “Oh, my God! This guy’s taking in a ton of milk. A ton of calcium – he’s got renal failure. He’s got hypercalcemia – this could be Milk-Alkali syndrome!” instead of doing a colonoscopy we should do an upper endoscopy, because all his symptoms are related to the esophagus. Sure enough he turned out to have milk-alkali syndrome. The renal people and the endocrine people changed their diagnosis. We proved it was milk-alkali syndrome. We did the endoscopy: he had roaring esophagitis with ulcers and with early Barrett’s esophagus [pre-cancerous change in esophageal lining mucosa cells]. This can lead to lead to carcinoma. But it was the art of history taking that helped out here. We learn from our patients, but we have to listen to them. We have to spend time with them. I had one patient, he had chronic Hepatitis C. He had a mild disease and at that time the treatment had [only] a 30% cure rate. So I said, “Listen, we going to follow you, there is no rush to treat this. This is a slowly evolving liver condition. There’ll be better treatments coming down.” Dr. Sanjiv Chopra, MD. One day I come to the hospital and I get an email saying he’s admitted to the ICU. That he is very sick. Dr. Sanjiv Chopra, MD. I go to see him and he’s being seen by hematology, he’s been seen by infectious disease and it turns out that he’s hemolyzing. He had gone to Martha’s Vineyard and Nantucket, he got bit by a tick. The Infectious Disease people made three diagnoses: he had Lyme disease, Ehrlichiosis. Babesiosis. All three from a tick bite. He’s very sick. But the house staff junior doctors sent me an email two days later: “Dr. Chopra, his liver enzymes are normal for the first time. I said, “Really? They’ve been abnormal for 15 years I have followed them. Repeat the test, maybe it is a lab error. Also send off a Hepatitis C virus RNA levels by polymerase chain reaction, let’s measure his viral load.” Dr. Sanjiv Chopra, MD. They repeat his liver enzymes and they are rock normal! He gets better, he’s discharged, he’s coming to my office 3 weeks later. I see him and that I said how are you doing? He said, “I’m getting better, I’m getting stronger.” Then I look at the computer, and Hepatitis C virus is Negative. Dr. Sanjiv Chopra, MD. I said to myself, “Maybe to fight the infections, the three infections he got, he mounted the most magnificent endogenous interferon response and it wiped out hepatitis C virus”. It is an RNA virus! Yes! Dr. Sanjiv Chopra, MD. I said, “You know what? Let’s test it again in six months. Your liver enzymes.” In 6 months results are normal, negative virus, six months later – normal, negative. I said, “You are cured!” He says, “Dr. Chopra, is this a new treatment for hepatitis C? Tick bite?!” Dr. Sanjiv Chopra, MD. We published it and there are rare cases of people with chronic hepatitis B who get superimposed hepatitis A. It knocks off the Hepatitis B virus. Dr. Sanjiv Chopra, MD. We are learning in medicine every day. We are learning from our patients, we are learning by history-taking, we are learning by just observing and not passing it off as an anecdote. “Oh, this is an anecdote – forget about it.” We need to document these discoveries.
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