Sometimes it pays to go the extra mile.

Today was my last day at my current site, and it ended on a soundly resonate note.

This site sees a lot of pain management patients, who are thus tested with toxicology screens once a month. These screens are urine tests which show any other substances in their system, such as cocaine, methamphetamine, or opiates other than those which they are prescribed.

I was doing a screen on a patient, a female in her 40s, and when I was doing the lab work I noticed a color to her urine that struck discord with my clinical sense. Although we are not to dip the urine of these particular patients with a standard lab dip (which will show the overall physiologic impression of the urine, for patients who we see outside of a pain management situation), I did anyways. Sure enough, it was positive for bilirubin and a significant amount of blood. Urine can sometimes show bilirubin in cases of dehydration or fasting (as well as pathophysiologic conditions such as hepatitis), but shouldn't normally show blood. It can show blood in certain situations, one being if a female is menstruating.

I went in and asked the patient if she was on her period, and she stated that she had a complete hysterectomy in 1996. She also had not recently engaged in sexual activity. So there was little chance the blood was associated with anything other than some type of pathology. What that pathology was, was unknown (it could be due to a plethora of possibilities, from kidney stone to UTI to cancer to etc). I did a thorough abdominal exam and found extreme tenderness to palpation at her RUQ (right upper quadrant), which narrowed the focus a bit.

I went to get my preceptor, the Doc who owns and runs the practice (the man who was an ER Doc for many years). I told him that I had done a standard urine dip on this patient, to which he responded fiercely that I should have consulted him before doing such a thing outside of protocol. I told him what I had found and we went to see the patient together. He examined her and asked her a few questions, then sat down to help her figure out what she should do next. I had already started seeing another patient, so I said, "my work here is done" and opened the door to leave the room. "Thank you", he said to me as I walked out.

Sometimes you just have to go with your gut.

5 more weeks at one last site, and then I will officially be done with my clinical year. If all goes well, I will then graduate and be ready to sit for the national licensing exam. Fingers crossed.