Ahem, I would just like to clarify that this post has been in my queue for over 2 weeks. Cranquis clearly looks up to me so much that he has assumed my writing ideas for his own blog (let’s just forget the fact, as I did, that this was actually his second CYOA post, because his first one was like decades ago in internet-years). Or maybe I’m just the Jekyll to his Hyde…
CHAPTER 1: It’s 4:53 on a Friday, and you’re wrapping up your last patient visit in clinic. For once, you’re running on schedule. Just as you turn the door handle to leave the exam room, your patient says those dreaded words:
Oh, by the way…
If you choose to blow off the BTW and schedule another appointment for your next available time, go to Chapter 6.
If you choose to sit back down and listen to the patient’s complaint, go to Chapters 25-28.
CHAPTER 6: Congratulations, patient 3 is dead. He had a massive heart attack in the Wendy’s parking lot at 5:58pm on Friday. You will go to his funeral on Monday, just after you meet with your lawyer (see chapter 9).
Patient 1 has been in a holding room in the ER since Sunday morning awaiting placement at a psychiatric hospital after having her very first psychotic break. She was found by police climbing onto the guardrail of an overpass, naked, and yelling at cars.
Patient 2’s follow up is scheduled for 3 weeks from Friday. However, he got a little swimmy headed the Wednesday after you saw him and fell in his yard, hitting his head on a birdbath on the way down. His son took him to the ER, where he was found to have a subdural hematoma. Your partner, who was on call, admitted him and found his hemoglobin was 6. To further work up his rectal bleeding, see chapter 7.
Patient 4 could not get a follow up appointment for another 6 months. To find out what happens in 6 months, check Chapter 8.
CHAPTER 7 While in the hospital, your partner, who does a much more thorough physical exam than you usually do, did a rectal exam on your patient. She describes feeling a large “polyp” in the rectal vault, just at the tip of her finger. The exam is also positive for frank blood. Patient 2 had a colonoscopy while in the hospital and was found to have adenocarcinoma of the descending colon and rectum. He had a partial colectomy during that admission and will be starting radiation in a few days.
CHAPTER 8 Patient 4 doesn’t remember why she’s coming in today. It’s been so long since she’s seen you! She looks terrible since you saw her last. She’s lost weight, she looks pale, and she tells you she had a seizure yesterday. She’s never had one before. You check your notes for any clues in her history. You never mentioned the BTW mole. You do a thorough physical, and she’s got some concerning neurological changes. You order a CT scan of her brain, and guess what: she has a tumor. A few weeks later, the biopsy comes back: malignant melanoma. She has 5 months to live.
CHAPTER 9 Your lawyer has warned you about the possibility of being sued. You made a big mistake, and you just hope your close relationship with the family is enough to protect you. You go to Patient 3’s funeral and meet his wife there. She is upset, of course, but she thanks you for “always taking great care of Bob” and the rest of their family. His death took her by surprise—I mean, he was only 57—but it couldn’t have been prevented, right? He never told anyone he didn’t feel well…
CHAPTER 25: You resign yourself to the fact that you will not be on time to your kid’s basketball game, and you close the door and sit back down. This sounds like it could be serious.
Patient 1 admits that she has been hearing voices for weeks now. They call her a failure and a whore, and they’ve made her realize that her husband’s bad attitude last night had nothing to do with a hard day at work. Obviously, her husband is plotting to kill her. She says must jump off a bridge to escape him. He can’t fly, so if she jumps he won’t be able to catch her, you see. You admit her to your hospital’s psychiatric ward that evening for her own protection and to start her on antipsychotic medication.
CHAPTER 26: Patient 2: After feeling a mass on patient 2’s rectal exam, you decide he needs a colonoscopy quick, though his last one 6 years ago was normal. Your nurse has a friend at the local general surgeon’s office and manages to get Patient 2 an appointment for a colonoscopy on Monday. They find that he does in fact have colon cancer, and after admitting him to the hospital he receives a blood transfusion for anemia. His prognosis is still not great, but at least you have spared him a head injury.
CHAPTER 27: You get a quick EKG on Patient 3 and find characteristic “tombstones” in leads 2, 3, and aVF. He’s having a heart attack. Your nurse gives him some aspirin to chew, a nitroglycerin to put under his tongue, and puts an oxygen mask on him while you call EMS and the cardiologist on-call for the hospital. He receives 2 stents in his coronary arteries just a few hours later. On Monday morning his wife will be waiting for you at your office with her famous caramel cake in hand.
CHAPTER 28: Patient 4 takes her shirt off and reveals a 3 cm purplish-black lesion with asymmetrical irregular borders. It looks suspicious for cancer to you, so you schedule her for a biopsy on Monday. The biopsy results come back next Friday: it’s melanoma, but the margins of the biopsy are clear. You caught it early, and it’s all gone.