Wednesday, June 13, 2007

petichiae

When Cal woke up this morning, I noticed that he had scattered petichiae all over his left hand, extending up to the wrist with a few spots on his forearm. There were no spots anywhere else on his body, and he was otherwise totally normal--happy, playful, no fever. But still, PETICHIAE. Lord. I went through my differential at once.

Best case scenario: some sort of unmonitored traumatic injury somehow. (Ponytail holder around the wrist? Sleeping on his arm funny? I don't know.)

Kinda bad case scenario: ITP, or some other scary unnamed reason for thrombocytopenia.

Worst case scenario: I can't even say it.

Granted, my level of alarm is somewhat skewed, as I have very vivid memories from my internship of taking care of a patient with fulminant meningiococcemia. He survived, but only after weeks in the ICU with Xigris and pressors and needing to get three of his four limbs amputated. Oh yes, not alarming memories at all.

I really weighed whether or not I should go into my regular pediatricians office or just call ahead to my homies in the Peds ER telling them I was on my way. But I decided that given Cal's otherwise completely normal appearance of robust health, I would try to take the non-alarmist route and lean away from going the route of maximal interventions by just taking him as a walk-in to the Pediatrician's office first.

The doctor we saw wasn't our primary, and--this is terrible of me to say this, what a hypocrite I am--she was probably only a few years out of residency, so I was immediately wary. She agreed that he looked well, and given that the petichiae hadn't spread anywhere beyond his left hand (I had very carefully circled the ones I noticed at home with a fine-tipped Sharpie, so that I could keep track), she figured that it was probably a result of some occult injury that we didn't catch, because Kids Do The Darndest Things and we really aren't on top of him 24/7. I would have felt better with a platelet count, but he doesn't have bruising anywhere else, even parts of his body that I witnessed him crunching and slamming just yesterday, so maybe the myriad etiologies of thrombocytopenia are less likely. "But if he starts to look worse, or gets a fever, obviously call us back," the Pediatrician told us. I smiled and nodded politely, but in my head, I was thinking that if I felt that anything at all was going south, I wouldn't be wasting my time trying to get through to the office's answering service, I'd be calling the Peds ER telling them that I was on my way over there postehaste. I don't have time to dick around, here.

Cal is fine. He had a fun start to his day (what with taking a taxi ride and a subway ride), played all morning, had a big slice of pizza for lunch, and now is sleeping. I'm glad, because by this point, I am mostly convinced that the petichiae was the result of some sort of mechanical injury. But still hard not to feel a little uneasy. I've seen too many bad things.

Sometimes I envy regular patients. Patients who don't know anything about medicine. Patients who trust their doctors. If I've learned anything from my four years of residency so far, it's how often doctors can be wrong.

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