Thursday, 21 August 2008

Good service

I have been a bit rude in the past about the time it takes to get through to my hospital colleagues for advice, so I must tell this tale of excellent service which I received today. I was perhaps lucky that I got through immediately, but the advice was also first class.

I've been seeing a young woman who has had persistent watery diarrhoea (but no blood) since she went on holiday to India a month ago. Stool culture has been negative and she has remained very well, apart from the persistent diarrhoea. The other day she saw my colleague who requested some routine blood tests, since we still did not have a diagnosis. The blood was taken this morning, and when I arrived for evening surgery the lab had rung through the results urgently. One of her liver tests, the ALT, was eye-poppingly high at 2,150. (Technical stuff for medics: her other liver tests were pretty unremarkable, the GGT was slightly raised but her Alk Phos and bilirubin were normal.) I asked her to come and see me at the end of the surgery, and she still looked extremely well with no signs of any liver problem (no jaundice, liver not enlarged). I was a bit unsure about what to do. The very high ALT indicates that her liver cells are sustaining a lot of damage, releasing the ALT enzyme inside them. Yet she was clearly far too well to require hospital admission.

So I rang for advice, and luckily the Medical Registrar on call was a gastroenterology Registrar who knows a thing or two about liver problems. The diagnostic process began. He told me that only three things can cause such a high ALT level: a paracetamol overdose, ischaemic hepatitis, and viral hepatitis. My patient is cheerful and optimistic and certainly hasn't taken an overdose. Moreover she is young and healthy, and there is no reason why the blood supply to her liver should have been damaged to cause ischaemic hepatitis. So she must have viral hepatitis. She can't have Hepatitis B because she was immunised against it when she started working in a nursing home, and is known to be immune. She has no risk factors for Hepatitis C (anal sex, sharing needles). But she was in India a month ago where it is very easy to catch Hepatitis A from contaminated food or water, and the incubation period is up to six weeks. In Hepatitis A the ALT rises first, and the bilirubin rises later causing jaundice.

There is no doubt that she is in the early stages of Hepatitis A, and we made the diagnosis by inductive logic before the patient became jaundiced and without a serology result. I shall wait for serological confirmation before I notify the disease to the Proper Officer, but I was able to discuss the diagnosis and management confidently with my patient. I was really pleased with the diagnostic help and advice given by the Registrar, and I have written to his consultant to say so. One good turn deserves another.

10 comments:

Jellyhead said...

How lovely of you to write to compliment someone, instead of to complain.

And great call on the hep A by you and the registrar.

Sometimes our jobs are stressful, but sometimes they're just plain fascinating, too!

Elaine said...

Was there no thought of immunisation against hep A - I had that before I went on holiday to China?

Elaine said...

Also I agree with Jellyhead that it was really good of you to take the time and trouble to pass on the compliment to the consultant; it is so easy just to make the complaints.

The Shrink said...

Hurrah, it's great when things just work!

Petra Huijts said...

Very small question...
Does it also explain the diarrhoea??

steph said...

A fortunate patient!

Well-played!

Paul said...

Very impressive

Oliver Smith said...

It was very good of you to take thetime to write a compliment. As has been said so often, it is so easy just to complain when things go wrong and not to compliment when things go well

Xavier Emmanuelle said...

Yes, taking the time to write a compliment letter is so nice of you, and I'm sure it meant a lot to the person.

Last semester I wrote a quick e-mail to a professor from another university who had an organic chemistry website up... I had been having some issues learning certain parts of organic chemistry, and his website was tremendously helpful not only to me but to my peers as well. I wrote him maybe a three sentence thank you note, but he wrote back and told me how much it meant to him to get some positive feedback rather than to constantly get complaints from students.

Dragonfly said...

I bet the registrar appreciated the positive feedback hugely.