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Let pain be your guide

As a resident, I am constantly learning.  And, I think, so are most of the attendings that help guide me.  Every so often there comes a case that is as startling as a splash of cold water.  The dangerous disease lurking behind the benign presentation can keep the hairs on the back of your neck erect for months.  Something very similar happened just yesterday.

In room 7 waited a 54 yo man with a history of kidney stones and a complaint of pain in his lower back.  I've never had a kidney stone and from what I have seen I am happy not to experience that pain.  This man held his lower back with his left hand and grimaced in pain, so I quickly put in orders for medication and told the radiologist to keep him in the cue for a CT scan.  We usually do not give contrast when we look for a kidney stone, which means that there is no dye running through his vessels, and the stone often appears as a bright rock in the ureter

After about an hour, when the scan was completed, that bright rock never appeared in any of the images.  And, despite receiving a heafty dose of Dilaudid, he still complained of a severe pain and clutched his lower back which was very tender to touch.  A healthy, middle aged man, with normal lab tests, and a normal non-contrast CT scan is usually pretty safe.  Nonetheless, his level of pain seemed to indicate something different.

Though my experience indicated that this patient was probably just fine, my intuition and his pain drove me to keep searching.  I checked his abdomen with an ultrasound, looking at his gall bladder which seemed normal, and I moved closer to his left, where his pain was, to look at his aorta which also appeared to be normal.  A constrast CT would inject dye thorugh his vessels and allows the scan to show more subtle findings such as a tear in the aorta.  We agreed to do this study and discovered that he did, indeed, have such a tear.

As I reflect on his case, I feel relieved that he is now doing well in the hospital and I am glad that we kept digging.  Sometimes pain is hard to control, but it is always our best guide to finding disease in any individual.  
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.