I have never been so happy to read quietly scornful notes that impugn my ability to practice medicine!
Okay, no one’s being snarky. And no one called me an idiot. But it’s clear that people are not impressed by the leukemia idea after review of the peripheral smear by people who…um…actually have a lot more experience with histological diagnosis.
Everyone seems to think I was right in the first place when I posited malaria as the source of his cyclical fever. Even though we didn’t see the plasmodia in the initial smear, they’re going to do serial smears see if they can catch sight of the little buggers that everyone thinks are probably lurking around somewhere in their reproductive cycle. Hematology is following along, and we’ve gotten Infectious Disease on board, too.
I feel good about keeping malaria on top of my differential, even though I had personally convinced myself about the leukemia thing. (I felt like it was too much of a coincidence timing-wise for leukemia to pop up and start causing symptoms right after the guy came back from Puerto Rico; malaria was much more likely when you took the timing into consideration and so I couldn’t justify putting leukemia at number one on the differential.)
I also feel good about keeping leukemia as number three (after malaria and dengue fever), so we could rule it the heck OUT, and be sure it wasn’t missed if it was there.
Assessment: The most likely diagnosis was number one on my differential list. The big bads were also there so they could be ruled out. (If you don’t think of it, you can’t catch it.)
Conclusion: I done right by my patient. But I clearly need more practice recognizing normal variants on a peripheral smear. Luckily I have a hematology/oncology rotation coming up in a few months!
Malaria ain’t great, but in an incredibly morbid conversation with one of my interns in which we ranked everything on the differential (from malaria to tuberculosis to HIV and many things in between) in order of what we would prefer to contract ourselves (yes, we do this sometimes), we agreed that we’d rather have malaria than leukemia.
Please join me in the happy dance of your choosing.
I call jitterbug!