Awe and Shock

Yesterday, my patient was a 37 year old man who was complaining of a dry cough for two weeks and progressive shortness of breath. He said he's had a heart murmur ("Something is wrong with my aorta valve," he said) since birth. And when I was asking him more about this cough and shortness of breath (SOB) he said that it's worse upon exertion, and at night, he can't lie flat to go to sleep; he has to use two to three pillows under his head. This is a classic sign of congestive heart failure-- it's called orthopnea, where basically fluid rushes to your lungs when you lie flat and so you have to be propped up. And so all signs led me to congestive heart failure, and I was like, bam, I got this!

So I started my physical exam and his pulses were fine, his respiratory rate was a little high, muscle power normal, cranial nerves intact. His lungs sounded clear. I palpated his abdomen and couldn't really figure out where his liver and spleen were, but I attributed that to the fact that I'm not very good at palpating those organs. And then I listened to his murmur. A loud whooshing sound as soon as I put my stethoscope to his chest. I probably could have heard it even without my steth! It obliterated his normal heart sounds. I could here it on the midline, but when I went to hear it above his mitral valve (which is like by the 5th rib, close to your left mid-clavicular line) I couldn't hear anything. Not even heart sounds. Just silence.

Part of me panicked. Was my patient going into heart failure as I was talking to him? Why couldn't I hear anything? And then part of me blanched. How stupid is my attending going to think I am, that I can't even hear the heart! Should I lie and say I did? Should I say I didn't and risk humiliation?

In the end, honesty won out. My attending ridiculed me a little bit, but said that we could check it out afterward. He laughed when I told him I couldn't palpate the liver, which made me feel a little small. By the time I was done presenting, my attending and I agreed that signs pointed to congestive heart failure, so we decided to go with that, while we checked his labs.

Oh, how wrong we were. Our patient was severely hypoxemic (he didn't have enough oxygen!- only about 50% as much as he should have been getting!) and as a result, his kidneys were releasing massive loads of this protein called erythropoietin, which goes and stimulates red blood cell production. So my patient was making astronomically high levels of red blood cells- so much so, that his blood had become ridiculously viscous. Like sludge. (Polycythemia, is what it's called.)

But then we came across the problem of trying to figure out why he was hypoxemic in the first place. So we went back to congestive heart failure once more. To see if we were right, we checked his CT scan, to check his heart, to see if it was big. And our jaws dropped. I think I squeaked.

Everything was wrong. Backwards, in fact. My patient had an EXTREMELY rare condition called Situs Inversus Totalis, which means all his organs were flipped. His liver was on the left. Spleen was on the right. Even his lungs were flipped! And his heart- he had dextrocardia. His heart was on the right side. Which is why, when I tried to listen on the left, I heard nothing. Situs Inversus Totalis. We learned about it in class a few weeks ago, and the only thing I could think was- that is SO COOL. It sounds like a spell from Harry Potter.

Now, I'm not sure why SIT would cause hypoxemia- maybe his enlarged heart was compressing on the aorta, and that, compounded with his leaky valve was doing the trick. I'm going to leave that up to the real doctors. I'm just going to bask in the glory that my second patient ever had a condition that was so rare, that my smart-ass, stick-up-his-butt (but ultimately a good teacher) attending had never seen it in his 30 years of practicing. Hmph!

Oh, and in case you are wondering how we treat for polycythemia (the sludge blood)? We blood let them. Yup. Leeches to Room 1088, stat!