Polite Dissent

Episode Title: In Which Addison Has a Very Causal Get-Together

The medical ethics were better this week (except for everyone looking in other people’s medical charts), but the medicine was equally questionable. This show would really benefit from some Grey’s Anatomy style continuing storylines; this patients-of-the-week format just doesn’t sustain the interest here.

Dr. Addison Montgomery and Dr. Sam Bennett
After seeing Sam on a local morning news show, a pregnant patient named Rebecca arrives in the clinic seeking medical care. She claims that she just escaped from the hospital because they were trying to kill her and her baby. She is five months pregnant, but surprisingly skinny. In short order, it turns out that she was involuntarily committed to the hospital because she was a psychiatric patient with Munchausen’s Syndrome, and now the hospital – and her mother whois her medical guardian — wants her back in the psychiatric ward.
Addison is not convinced that Rebecca has Muchausen’s, though some lab values which suggest she has not been eating give Addison pause. In the end, the team gets the hospital to run a capsule endoscopy (”GI camera”) which reveals that Rebecca has Crohn’s Disease — a type of Inflammatory Bowel — and not a psychiatric disorder.
Five months along and she is just now feeling the baby kick? That’s not a good sign.
I’m concerned by the amount of x-rays and CT scans performed on Rebecca. There was an entire wall full. Radiation is not good for developing babies. (And if the Crohn’s was that bad, something should have shown up on the CT).
Involuntary psychiatric admission laws vary greatly between states and I’m not familiar with the laws in California. I can see an involuntary admission being granted in this case though, for fear of Rebecca harming herself and harming her baby.
I’m not sure what labs would show Rebecca hadn’t been eating when she claimed she had been. Albumin and other proteins can be low in malnutrition, but that’s in the long term, not short term. Ketones in the urine can also suggest starvation — though it can mean other things as well including diabetic ketoacidosis and an Atkins dieter.
I don’t know why the team was thinking they could get a capsule endoscopy performed in under an hour. It takes the better part of a day to run a capsule endoscopy, let alone the prep beforehand. An actual colonoscopy would be faster and give more definite answers.
There are simple blood tests to detect active autoimmune diseases. They’re not always good at pinpointing which disease in particular, but would at least let the team know that something physical is going on.
Sam uses the word “occult” way too many times in this episode.

Dr. Cooper Freedman
Cooper was dealing with Michael, a ten year-old boy who was in love with a friend. When Cooper encourages Michael to ask his friend out, the boy returns to the office bruised and bloody. It was not a girl he asked out, but another boy. Now he runs away and Cooper — of course — finds him and manages to bring him back home.
No skateboarding or contact sports if you have Mononucleosis because the spleen can become enlarged during Mono and there is a chance of rupturing it with any blunt trauma.

Dr. Violet Turner and Dr. Naomi Bennett
Violet become obsessed (well, more obsessed) when she sees her ex-husband’s (or is it ex-boyfriend’s — it’s not clear) new wife visiting Naomi. It turns out she was there to be treated for a urinary tract infection, not pregnancy as Violet feared.
Violet’s one note characterization is quickly becoming tiresome.
What kind of doctor is Naomi exactly? Who goes to see a fertility specialist for a UTI?

Dr. Pete Finch
Pete is seeing Stan, the curmudgeonly fiancée of Sylvie, an old patient of his. Stan has been having fainting spells and Sylvie is secretly concerned that the fainting spells are a subconscious sign that Stan does not want to marry her. Pete runs some “basic tests” which are all negative, but after some more probing, he determines that the Arthur has a “trigger point” that causes a “painless migraine” (a type of Atypical Migraine) which causes him to pass out when he is in certain positions.
An EKG, echocardiogram, and carotid Doppler all are good tests for this situation. Some sort of head imaging is indicated, but I would never consider an MRI a “basic test.” Maybe that’s just because I practice in small town Illinois and not a big city in California.
As for a muscle trigger point causing a painless migraine, that’s a rather cavalier diagnosis. I have seen atypical migraines that cause symptoms that look just like a stroke, but never one that causes passing out, one that shuts one and off that quickly, or one caused by a “trigger point.” I’m not saying it can’t happen; it’s just quite a stretch.