HIV and ID Observations

In an era where control-c followed by control-v — that’s cut and paste, for those of you who don’t use keyboard shortcuts — is the prime method by which most clinicians write their medical notes, I’d like to come right out and brag that ID doctors take the best medical histories.

You could argue (as I have before) that we do this because we suffer from variable (but mostly extreme) degrees of OCD. Or that it’s because we have no billable procedure. Or that we’re just being kind to the clinicians responsible for dictating discharge summaries, and want to offer them a little spice for their otherwise routine narratives.

But in reality, we are motivated by a quest for that “a-ha!” moment, when some scrap of history leads to the diagnosis that — with this critical piece of information — becomes oh so obvious. At least to us.

You know the type:

• The avid golfer who develops cough, pneumonia, and erythema nodosum — and tells you she has just played in a golf tournament in Arizona. (After being informed she has coccidioidomycosis, her first question was why the diagnosis wasn’t made in the Minute Clinic she went to in Scottsdale. Good question!)
• The gardener who is evaluated for a series of bumps on his back — Nocardia brazilienses, of course — and tells you he regularly uses one of his trowels as a back scratcher at the end of his work day.
• The diabetic with a wound infection from Aeromonas hydrophila, who describes using week-old tap water he keeps by his bed to soak the gauze for his wet-to-dry dressings.
• The biology grad student with high fevers and a severe sore throat, who says he just came back from Burma, where he spent most of his days in the jungle setting up large tarps to collect urine from tree mammals. Diagnosis? Burmese Pharyngeal Fever, of course.

(I made that last one up — he just had strep throat. But the exposure history was awesome, wasn’t it?)

Making one of these diagnoses from the history is, for an ID doctor, the equivalent of resecting a large tumor successfully, or doing an emergency cardiac cath on a patient with an acute coronary syndrome, or performing a face transplant.

It’s our version of, “So we took him to the OR, and saved his life.”

So it was with interest that I read this case series on severe Pasturella multocida (notorious cat and dog bacteria) respiratory infections in three people who provided palliative care — to their pets! Summarized in Journal Watch by Abbie Zuger, the paper has these choice historical items from the cases:

A further detailed history revealed that the patient’s pet dog died several days previously, that the patient had provided palliative care to the terminally ill dog by dropper-feeding honey to the dog, and that the patient had co-consumed honey with the dog by licking the same dropper used to comfort-feed the dog…

Further history revealed that 2 weeks prior to her illness, the patient had provided palliative care to her dying cat by holding, hugging, and kissing the head of the cat and allowing the cat to lick her hands and arms …

Simply asking whether or not the patient had a pet would not have uncovered the defined association of these respiratory illnesses with palliative pet care. The patient with P. multocida uvulitis even denied having a pet (it had died 6 weeks previously) and only admitted to having provided palliative pet care when asked specifically if she had any animal contacts in the past 3 months.

So the next time someone makes fun of us for asking patients about their pets (current or, sniff, recently deceased), or travel, or dietary habits, or sexual escapades, or home improvement projects, or assorted hobbies, we should stand our ground — because ID doctors take the best medical histories.

Have I made my point?