My own personal Yedi

Hot diggity dog, boys and girls. Today was a good 'un. Not just because I got off twenty minutes early and had pizza and cupcakes for dinner. Or even because it finally rained. A lot.
But because I made a mad crazy, wicked cool diagnosis at work. Well, I didn't actually do the staining of the kidney biopsy that showed the diagnosis, but I definitely called it on the day of admission. "Blah blah medical jargon blah blah. Amyloidosis is equally far-reaching but should also be considered as it would unite her various, seemingly incongruent symptoms. Recommend blah blah more boring medical jargon." It was in my note within two hours of admission. And 12 days later, abracadabra, alakazam!
And let me tell ya, kiddos, it's a rare one. Light chain amyloidosis without a monoclonal paraproteinemia? Whew! This is one of those things that people talk about second-hand; so-and-so from residency said his attending saw one once. But no one ever actually sees with her own eyes! And I did.

That is all. Peace.

A little advice

A direct quote from my most recent consult note:

"She does not have any other signs or symptoms to suggest autoimmune or inflammatory connective tissue disease to me at this time. Therefore, would NOT get other "autoimmune" labs right now, as some would likely come back false + in setting of infection and therefore be difficult to interpret accurately."

Translation: Do not, I repeat do NOT, order an ANA. Or I may get angry. And you won't like Bethie when she's angry.

Life of pregnant Bethie: The monster within

Gizmo is not only getting bigger every day, she's getting more aggressive active. You can even feel her moving from the outside, which is the only thing weirder than the fact that I can feel her moving on the inside.

Pertinent digression: Remember that scene from Jurassic Park where the water glasses quiver as the T rex draws near?

The real story: Last night, I finished a phone call and set my phone down. On my belly. Because you must remember, it is my own personal goes-everywhere-I-go table. Then Gizmo kicked, and the phone wobbled, just like that video. I hope it's actually a baby and not a dinosaur in there.

Go ahead, make my day

Yeesh. That was a long, busy kinda day.I went into rheumatology to avoid 12-hour days, but that plan didn't work out so well for me today. At the halfway mark, I was draggin'. Clinic was comprised of 2/3 "I hurt all over" and 1/3 +ANA. And then I got a call about a gout attack (digression: wouldn't that be a totally awesome band name?) they needed me to stomp out. Needless to say, I was slightly less than enthused. And then I remembered.

I remembered the Ghiradelli chocolate square tucked in my lunch box. Happy sigh. Just what I needed.

So I guess I stand corrected. Steroids don't fix everything. Sometimes only chocolate will do.

Broken record

My day, in a nutshell:

1) It's not lupus. Trust me.

2) Don't stop the steroids. Ever.

3) It still isn't lupus. Just ain't.

4) Did I telepathically detect you thinking about stopping the steroids? Quit that tomfoolery right now.

5) No lupus.

6) Yes steroids.

Get the picture?

Octogenarians say the darndest things

I invited myself to Waco last weekend. More specifically, Angela's house. But more on that later. I also attended my first Baylor football game as an alum. This was an especially nice treat since 1) my friend Mike has nicely located season tickets and 2) Baylor won. And not just won, but got the game called in the third because of a >40 point lead in the midst of an impressive lightning storm. But that isn't the point. The point is this. As we were clambering out of the bleachers just before the half, we passed an adorable little old couple, all dressed in Baylor green and gold.

Me: Excuse me.
Adorable little old man: I hope they didn't charge you an extra ticket! [gesturing at my ever-expanding baby-incubating belly]
Me: Nope. I snuck her in!
ALOM and wife: [genuinely tickled laughter]

I think I made his day. Adorable. Just adorable. I hope Nick and I are that cute when we're old.

Absolutely positively

Sorry, I got distracted. Never got around to the third and final installment in the Most Common Rheumatology Chief Complaints series. But better late than never.

1) +ANA

As a preface, ANA is an autoantibody. People order it and then don't know what to do with the results. That's where I come in.

Me: In one sentence, what brings you to a rheumatology office today?
Patient: My lupus test is positive, so my doctor sent me to see you.
Me: You mean the ANA?
Patient: Yeah, my lupus test.
Me: Well, the ANA isn't exactly a test for lupus. But we'll talk about that. What symptoms did you have that made your doctor want to run those tests?
Patient: [The following are selected examples.]
1) I tried a new moisturizer, and my face broke out in a rash. My doctor was afraid it could be lupus.
2) My low back's been hurting for the last several years, ever since my car wreck. I just can't take it anymore. My doctor thought maybe the reason the pain wasn't going away was lupus.
3) I sneezed like 14 times in a row the other day. My doctor thought it might be lupus.
4) I'm just tired all the time. My doctor thought it might be lupus.
5) I get urinary infections all the time. My doctor thought it might be lupus.
Me: Sigh. OK. Let me ask you some other questions. [Big breath] Do you have rashes on the skin, hair falling out, sores in your mouth, sores in the eyes, super dry eyes so you can't wear contacts, super dry mouth so you can't swallow down crackers, fevers or infections, trouble breathing, pains in the chest, palpitations, cough, coughing up blood, coughing up sputum, belly pain, nausea, vomiting, diarrhea, constipation, blood in your stools, dark dark black stools, burning when you pee, blood in the pee, super foamy pee like a head of beer in the toilet, joint pains, swollen joints, red joints, muscle aches, ever had a blood clot in your legs or lungs, trouble bleeding like you cut yourself shaving and it just won't stop, numbness or tingles anywhere?
Patient: Well, sometimes I get constipated if I don't take my fiber.
Me: Great news. You don't have lupus.
Patient: But my lupus test was positive.
Me: You see, the ANA isn't exactly a test for lupus. It's a generic screening test, so just because it's positive doesn't mean you have lupus. There's lots of perfectly normal, healthy people with positive ANAs.
Patient: But if I don't have lupus, why do I [insert previous examples here].
Me: Maybe you just had
1) an allergic reaction
2) mechanical back pain
3) a bad day
4) sleep apnea
5) plain old urinary tract infections.
But the good news is, you don't have lupus.

Thank you for this interesting consultation. The patient has been seen and discussed with Dr. A, who agrees with the above assessment and plan.

Sincerely,
Beth Scholz, MD
Rheumatology fellow, PGY-4

Dolor aqui?

Because I know you're on the edge of your seat from last time, I thought I'd enlighten you today about my #2 chief complaint: hurts all over.

Me: So, in one sentence, tell me what brings you to a rheumatologist?.
Patient: Well, I had the back injury 25 years. And then there was the car wreck with really bad whiplash 17 years ago; can you believe they didn't take away his license, after hurting me like that? I mean, I could have died. And then they did that surgery 9 years ago...*
Me: I'm sorry. But why are you here today?
Patient: I was telling you,..
[I'll spare you the painful details. Ten minutes later...]
Me: So you have chronic pain?
Patient: Yes.
Me: Where does it hurt the worst?
Patient: All over.
Me: But if you had to pick one spot, where does it hurt the worst?
Patient: All over.
Me: No, it would really help me if you could take one finger and point to the spot that hurts the absolute worst.
Patient: Here. [Takes one finger and makes circular gesture from chin to knee and back.]
Me: Well, I've got great news. You don't have lupus.
Patient: What? Well then why do I hurt everywhere?
Me: It isn't lupus. Lupus doesn't do that. Lupus gives you funny rashes and ulcers and makes your hair fall out. It doesn't make you hurt all over.
Patient: But I read all about lupus on the internet!
Me: Well, the good news is that none of those things are happening to you.
Patient: Well, I don't know. I may get a second opinion.

Thank you for this interesting consultation. The patient has been seen and discussed with Dr. A, who agrees with the above assessment and plan.

Sincerely,
Beth Scholz, MD
Rheumatology fellow, PGY-4
*You have just failed my "follows simple commands" test. One sentence, people, one sentence.

Pain in the what?

I love rheumatology for all the bizarre and esoteric diseases, but let's be honest; I pretty much see the same three complaints over and over.

1) +ANA
2) hurts all over

We'll get to those some other day. Today's featured chief complaint is...
3) I don't know.

Me: So, in one sentence, tell me what brings you to a rheumatologist.
Patient: I got the appointment card in the mail.
Me: Sigh. OK. But why did you get the appointment?
Patient: Because my doctor made it for me.
Me: Bigger sigh. OK, but why did your doctor want you to see me?
Patient: I don't know.
Me: Biggest sigh ever. Any problems with your joints lately? Or rashes?
Patient: Nope.
[Insert an hour's worth of detailed medical questioning here.]
Me: Well, I've got great news. You don't have lupus.

Thank you for this interesting consultation. The patient has been seen and discussed with Dr. A, who agrees with the above assessment and plan.

Sincerely,
Beth Scholz, MD
Rheumatology fellow, PGY-4

Eye on the prize

Gizmo just keeps getting bigger and bigger every day. I hear it's what babies do. The downside to this is that I keep getting bigger and bigger every day. Bummer. A closet full of great clothes that don't fit (right now). A la water, water everywhere, and not a drop to drink. And the thought of all the extra exercise and dietary discretion in my future to get back to my usual self is down-right discouraging.
But then I stumbled onto this store - Shabby Apple - and found my reason not to give up. Think Anthropologie but less boho, more uptown. Oh, it's just beautiful. And it's my reward. In however many months, when I'm back to "normal," a new dress from here shall be my reward. The hardest part about that is going to be picking just one.

Umm...

I only had one new consult all week. That might be a record. But it was a doozie. The patient has a neurological problem, which kind of renders her unfit to tell her own story. As in, she thinks the telemetry box is a cell phone. Problem. Her family isn't in the room and didn't answer the phone. Another problem. She's on a surgery service, so the notes lean a little to the Spartan side. Yet another problem. Our Sherlock-Holmes-ian attempt at investigation this morning (including googling rheumatologists in her hometown) twas all for naught. Rounds went something like this...

Attending: So when was she diagnosed with lupus?
Student: I don't know.
Me: Because the patient can't tell us.
Attending: And who made the diagnosis?
Student: I don't know.
Me: Because the patient can't tell us.
Attending: And what meds was she on at home?
Student: I don't know.
Me: Because the patient can't tell us.

I wish I could tell you she woke up and told us everything, or at least that we fixed her with steroids. But in the end, this is what we got...

Me: So what do you think? Is it her lupus? Should we pulse her?
Attending: I don't know.

Say it with food

Not much going on this weekend. Although I feel like I've kept myself busy, I couldn't tell you what I've done. I definitely haven't gotten as far with my next case conference and journal club presentations as I would have liked. But there's always tomorrow because I have Labor Day off for the first time in years! Nick has Labor Day off, too. Since he starts his job Tuesday, I decided a little Pre-Labor Day celebration was in order today. As in, pre-actual holiday and pre-new job.
This "celebration" mostly involved food. I braved the maddening crowd at HEB this afternoon; I'll spare you my long tale of annoyance and woe in the check-out line and get straight to the good stuff. Steak. Lots of steak. And twice-baked potatoes. And asparagus with shallot-garlic butter.

And my man at his new grill.

The fruits of our labor.

And thanks to HEB's strategically designed den of temptation, I got coupon-ed into a package of Oreos with my milk purchase. Which means I'm gonna test that Oreo Fudge bar recipe I favorited so very long ago. I'll let you know how it goes.

P.S. I promise the next blog will not be about food.

P.P.S. Well, not JUST food. I'll talk about something else, too.

P.P.P.S. I just remembered that I never told you how very swimmingly my mint ice cream trial went last month. Deeeelicious. But I don't think it will be worth the decimated mint plant very often. However, I now have a wonderfully smooth ice cream base recipe with cooked (!) eggs that I love. That is all. Good night, and happy Labor Day.