The majority of the time, incidental findings are benign, nothing to worry about: small meningiomas, renal cysts, ovarian cysts on CT scans gotten for other reasons, granulomatous scars on xrays, and so on.
But every now and then, they turn out really bad. I think this has to be the worst kind of bad news you can give a live patient: they came to the hospital because of something else entirely, and now you have to explain that because of this test you did, you found out that their life is going to change forever. With other bad diagnoses, at least the patient knew they were sick with something. But out of the blue. . .
When I saw that the admission diagnosis was new-onset seizures, I jumped at the chance to see Anna. Previously I’d seen several patients with a history of seizures, for whom management consisted of verifying that these were nothing different, and adjusting their medications. Anna, on the other hand, would need a complete workup. Twenty-something isn’t too old to develop epilepsy, but it’s unusual.
In a hospital gown, lying in bed surrounded by anxious relatives, Anna looked a lot younger than me, although she’s actually a few years older. The whole time we talked, she looked surprised and bewildered. She’d been babysitting her niece, when all of a sudden she felt hot and dizzy. The next thing she knew, there were EMTs walking into the room. Her older sister had walked in and found her in what sounded like a grand mal seizure. That was it. No risk factors in her family or social history (ie, no epilepsy in the family, no heavy alcohol or drug use recently).
The CT scan done in the ER showed nothing, but just to be thorough, because some causes of seizures can’t be seen on CT, we got an MRI too. That’s when the problems started. When Dr. Army looked at the MRI, he had to recheck the patient’s name and history, because it looked like a prototypical multiple sclerosis MRI. So we went back in Anna’s room and asked a bunch of questions, looking for overlooked symptoms of MS. She couldn’t remember anything significant. Her job has long hours and she’s on her feet a lot, so there’s fatigue and leg pain, but who knows what caused it? Then Dr. Army went over the neuro exam and, being twice as strong as me and more thorough, managed to elicit some left-sided weakness in a few unconnected muscle groups.
So she got a lumbar puncture. Attempted by yours truly, and for once I felt absolutely no guilt about practicing on patients. She needed the procedure (we didn’t make it up for my benefit; hospital lore has it that surgery residents are prone to such proceedings, but I can’t imagine why, since all the ones I’ve ever met have done so many procedures they’re bored sick of them, and would rather imagine away the ones that do exist, rather than create unnecessary ones), and Dr. Army gave me a very careful lecture on the subject beforehand (another reason to love him: he subscribes to the school of not giving the medical student too many instructions right in front of the patient, for both parties’ sakes). I got a lot closer than I ever have before, not running into bone two inches in, but I still couldn’t find the spinal canal. Dr. Army, of course, hit it right away.
CSF studies showed nothing. The particular study for MS, oligoclonal protein bands by electrophoresis, won’t be back will next week. Her EEG looked normal, so Dr. Army gave her the option of going home without any medications, and waiting to see whether she would have another seizure. Of course she jumped at the possibility. He had previously explained to her and her family about the plaques on the MRI, and their probable significance. Anna looked overwhelmed; as if new seizures weren’t enough, she has to adjust to the idea of having a crippling disease, when she felt perfectly well.
That was Wednesday. She was discharged Thursday, while I was gone for Match. I came in on Friday, and got a very bad feeling when I saw her name back on our list. She had come in to the ER overnight, having had a second seizure at home, which her mother claimed had lasted for ten minutes. (Ten minutes is bad; you hope seizures stop in five minutes or so; more than that is a sound reason for calling 911.) Then, after being on a dilantin drip for an hour in the ER, she had another seizure, although much briefer.
She was not happy. Three seizures in three days, after we’d told her she should hopefully be ok for a while – on top of the MS. Dr. Army wasn’t happy either. These seizures were coming too fast, starting too abruptly. He was starting to wonder whether there wasn’t some significance to the MRI findings other than MS. Most neurologists say that MS predisposes to seizures, but Dr. Army is slightly iconoclastic, and he thinks there’s no connection. So the MS plaques and concomitant seizures weren’t self-explanatory, for him. Further workup indicated. . .
That was my last day in the hospital. Next week I’m supposed to be in the outpatient offices. I hope I can track down Anna’s labs as they come back. I hope there’s nothing else unusual to turn up. She’s had enough for now.