It’s probably the rare parent these days who hasn’t read If You Give A Mouse A Cookie, an adorable book by Laura Numeroff. In it, a little boy gives a cute mouse in overalls a cookie. This one little act sets off an exhausting chain of events that eventually comes full circle.
I was recently reviewing old records on a new patient. I noticed that he had had an awful lot of tests over the previous couple of years, which struck me as odd, given that he was a pretty healthy person. Looking a little further, it seemed that a cascade of events had been set in motion that had started with one innocent little test- which was not even indicated.
This patient was a former smoker, having quit many years ago. His previous doctor ordered a chest x-ray to screen for cancer. This was unnecessary in the absence of symptoms as it’s a category D recommendation by the USPSTF. Nevertheless, the doctor ordered it and the patient had it done.
And, with apologies to Laura Numeroff:
If You Give a Patient A Chest X-Ray
If you give a patient a chest x-ray, the radiologist will see some tiny nodules.
The radiologist will call you and recommend a chest CT.
When he gets the chest CT, which is otherwise normal, the radiologist will note some calcifications in his aorta. This will make you nervous, and you will refer him to a cardiologist.
Because this is a cardiologist, in addition to ordering an aortic ultrasound, he will also order a stress test, echocardiogram and carotid ultrasound.
All of those studies will be normal, but the ultrasound tech will notice a thyroid abnormality. This will cause you to send the patient for an endocrinology consult.
The endocrinologist will redo the ultrasound. Then he’ll order a thyroid uptake scan. This will show an active adenoma
, which is benign, but he’ll recommend follow up ultrasounds every six months after that. He also notices that the patient is slightly hypothyroid
, and starts him on levothyroxine
The medication elevates the patient’s blood pressure, so you start him on an ACE inhibitor
The patient comes back to you two months later with an ACE inhibitor-induced cough.
And if you see a patient with a cough…you’re probably going to want another chest x-ray.