Saturday, September 27, 2008

A Cushing's Referral

From http://doctorslife.blogspot.com/2008/09/referral.html
I referred a patient to my alma mater today.

And I have to say, it felt a bit weird. To be calling WFMC, to be faxing in the paperwork TO them, instead of WITH them.

It was a case of Cushing Syndrome. Always difficult, these cases, because lab results are often equivocal, and often contradictory. Case in mind, guy who previously had a normal 24 hour urine free cortisol. I did a 1 mg dexamethasone suppression test which was negative, yet close enough to being positive that it just didn't smell right. And so I repeated the urine studies which this time came back positive. And did a salivary cortisol, further confirmed by the 2-day low dose dexamethasone suppression test I did, with a nonsuppressed ACTH.

His MRI showed a pituitary microadenoma. Presumptive diagnosis: Cushing Disease. Personally, I was confident enough of the diagnosis that I didn't think an IPSS (inferior petrosal sinus sampling) was necessary. But the neurosurgeon wanted that, and it's not something we have readily available here.

So, he's headed up to see if they feel he needs the IPSS, or if they are willing to operate on him based on the data I've collected thus far.

It's a strange feeling sending the patient up. In a way, it's pride, telling the patient that if I was going to have pituitary surgery, it would be by one of WFMC's neurosurgeons' hands. And another, that near-gleeful feeling, reminiscing and telling the patient how the system there works, and the qwerks of some of the consultants there and helping choose a consultant and surgeon for them, based on what the patient wants. And yet, mild anxiety, sending a patient to your ex-mentors and teachers, not as a fellow of theirs anymore, but as a colleague, hoping that when they read your referral letter and see your patient, they go

"Ah, Dr. Vagus did a good job working him up. We taught him well."

And not

"What on God's green earth was that idiot doing?? This patient doesn't have Cushings!!"

I think they taught me well.

I hope.

We shall see when after they are done with their evaluation.