You Think

This Budd's for You

Today was a late day. I did not get all my dictations done in time because I was Budd-Chiari-ing.

Budd-Chiari-ing is when your last patient in the morning comes to see you and he is young and without any medical conditions except he spontaneously developed Budd-Chiari syndrome for no reason 2 weeks ago. And they discharged him from the hospital despite ongoing fevers and no diagnosis. And now in your office he has a temperature to 103 in front of you and feels sick. But his blood cultures were negative before.

And you look on Up-to-Date for all the Causes of Portal Vein Thrombosis and check them off one by one as you determine they are unlikely, looking in the mouth for ulcers (Bechet’s disease) and palpating the testes for tumors (hypercoagulable state?) And then you look up Fever of Unknown Origin.

And then you call a bunch of specialists and stay through lunch hoping the Infectious Disease guy will call you back and the GI doctor does but he tells you a bunch of tangential anecdotes and the Heme-Onc guy doesn’t think it’s a Heme-Onc issue but gives you advice anyway that is in conflict with the GI doctor’s advice.

And it’s time to see more patients so you order some labs and arrange to speak with them by phone in the next 48 hours. And you call the ID doctor again and he ignores you.

And you think and you think and you think.

And you see some more patients.

And finally you talk to the Dinosaur. He’s got a few minutes. You sit together and look everything over one more time.

“I’d order an RF, CRP, ESR, CBC, and repeat ANA, as well as repeat blood cultures.”

Yep, that’s what I had already ordered.

“Sorry I can’t help more than that though. I really don’t know what’s going on.”

Somehow, this was reassuring. I was on the right track. And a very smart someone had no better idea what was going on than I. It shouldn’t be reassuring, but it was.

After Budd-Chiari-ing all day, one still has to complete one’s notes. So that’s what I did. I was the last one leaving the clinic. Outside, snow covered everything. It crunched underneath my feet.