Incidental findings:
History of present illness

Jimmy, 10y/o M with depression


Her hope was that getting pregnant would fix her marriage, but instead, at 14 weeks, he left her. These were the circumstances under which Jimmy was brought into this world. He and his mother stayed with his grandmother for several years while his mom tried to find a new man in her life. She'd come home drunk sometimes, or wouldn't come home at all for days at a time. She left Jimmy's grandmother to change the diapers and take care of the feedings and the restless nights. No one ever saw his first steps or heard his first words. Jimmy's earliest memories were of his detached grandmother, and of his mother, passed out reeking of beer and cigarettes.

Eventually, she found Mike, and it was only a few months before she moved in with him. Jimmy's grandmother was furious. She screamed at Jimmy's mom, using big words he didn't understand, like responsibility. The argument ended with his grandmother opening a suitcase and throwing all of Jimmy's worldly possessions into it. She sent the both of them out the door, and so, at age 5, Jimmy saw his grandmother for the last time. She died a year or two later, but Jimmy wouldn't find out for years.

After a few months with Mike, things started changing. It happened one Saturday morning. Jimmy was up watching Power Rangers. His mom and Mike were still in bed after partying all night. Jimmy heard some commotion from their bedroom, and then yelling, and then screaming. Suddenly, silence. A minute later, Jimmy's mom came out, picked him up by the collar of his shirt, and she started yelling. The TV was too fucking loud. He had to turn it the fuck down. She threw him to the floor and he hit his head. Jimmy started crying, and so his mother backhanded him across the face. Jimmy shut up.

At age 6, his mother didn't see the need for a babysitter anymore when she and Mike went out. She would lock Jimmy in the closet. Sometimes, she'd forget to let him out till the next morning. The first time he soiled himself, she hit him so hard across the face that he couldn't feel his jaw. He learned his lesson. After that, he ate like a bird and barely drank any liquids. He wouldn't make his mother angry again.

His first trip to the ER was after his mom slammed his head into a concrete wall. 9 stitches. The doctor made a note in the chart - thin, dehydrated, small for his age. Jimmy was sewn up and sent home with his mom.

The next time was only a few months later. Jimmy heard screaming coming from his mom's bedroom, then crying, then quiet. An hour later, she came out of the bedroom, stepped on one of Jimmy's toys, and without word or warning, picked him up and threw him against a cabinet with glass doors. He went right through it. Far more than 9 stitches this time. His mother was sobbing hysterically in the ER. This doctor also noted that Jimmy was underweight and undersized. He went home with a can of PediaSure.

His third trip to the ER, a week after his 7th birthday, was for a spiral humerus fracture. The radiologist went so far as to say "Highly suspicious for abuse" in his report. And the ER doc took another look at the little 7 year old, who had never spent a day in school in his life, who had more trips to the ER than some people do in their lives, whose height and weight hadn't changed in 2 years, who was a patchwork of scars and bruises, who had his arm twisted until his brittle bone gave out, and it wasn't hard to call the social worker. And the social worker took one look at Jimmy and called protective services without even reading the chart.

He didn't go home after that. He stayed in the hospital for a few days. He had a cast on his arm which all the nurses signed. There were other kids around that he played with. It was fun, being in the hospital.

When it was time to go home, it wasn't his mother there to pick him up. She looked like his mother, but was older. Aunt Karen, she called herself. She was in tears, meeting Jimmy for the first time. Aunt Karen lived alone, and she didn't know the first thing about raising children, but when she met Jimmy, she was willing to try.

The first thing she did was try to get him to eat. She'd put plates of food in front of him, good things like cheeseburgers and chicken nuggets, ice cream and soda. Still, he'd just nibble and sip. Over the course of a few days, she began to find food hidden all over the house. She forced him to drink nutritional supplements, and every night was ice cream.

She tried to get him to stop cursing so much. Jimmy didn't understand. He wasn't supposed to say fuck or shit or bitch or cunt or any of those words. It was weeks before Jimmy even could figure out what words Aunt Karen meant. Whenever he'd happen upon one, she'd stop him and gently tell him that's not a word that children should ever use.

Jimmy went to school for the first time. He had no concept of school. It was hard, being around all those people, all strangers. He was behind in every subject. His teachers worked extra with him, and tutors would come in after class and help him him along. What he really enjoyed about school were the school supplies. He had pencils and notebooks and a full set of crayons. He tried never to use them. The teachers had to encourage him to use all those supplies that sat in his desk. Aunt Karen got a call one day at work. Jimmy was inconsolable. He had lost one of his crayons.

After several months with Aunt Karen, Jimmy was adjusting to this new life. Aunt Karen thought it would be okay for her to go on a date. She had the neighbor girl Missy come over to watch him. She met Jimmy and shook his hand. He was very quiet and withdrawn. Karen wasn't more than a few feet out the door when Missy called her back. Jimmy was hiding somewhere, and she couldn't find him. Half an hour of searching, and they finally found him crawled into the linen closet, sitting in the dark, nibbling on an animal cracker.

And for two years, Jimmy and Aunt Karen lived together, and she tried her best to give Jimmy a normal life. And it almost seemed to be working until Jimmy's mother came to visit. She was trying to get her life together. She smelled of whiskey and cigarettes, and she had a large black eye. She made it about 3 steps in the door before Karen pushed her back outside.

Karen sent Jimmy's mom away, and she left without much fanfare, but Aunt Karen had to pry Jimmy off of her. After she had left, Jimmy was utterly distraught. Where was mom going? Why wasn't he going too? Didn't his mom love him? He was nothing but tears all night. And the next day. And the next night. And he lost interest in his toys, and he stopped participating in school. It was as if two years of love and nurturing were all undone in 10 minutes.

And so Aunt Karen took Jimmy to the doctor because she had nowhere else to turn. And then to a child psychiatrist. And then to his social worker. And then to a child psychologist. And the question he asked each one of them was when he could live with mommy again.

I can't stress enough, this is not a real person, but it certainly is the sort of thing I would see every day as a student on child psych at med school. And the true shame is that for most of these kids, there is no "Aunt Karen" to take care of them. They go to foster homes and sometimes find themselves in worse situations. And it's compound tragedies of child psych which finally convinced me to stop and to pursue something else for a career. By compound tragedies, I mean things like an abused child goes into foster care, gets sexually abused, is placed in another home, scrapes by until 18, abuses drugs or alcohol, has a child, and then abuses that child. I just couldn't bring myself to do that for a career. I was too sensitive for it. To us, it's the most awful of tragedy. To the child psychiatrist, it's his 8:15 appointment. And maybe this was selfish of me, but I never wanted to be cold to tragedy like that.

James, 46y/o M with ischemic limb


James lived in an average home, in an average neighborhood, on an average street in an average town. He ate average meals, had an average wife, and the average number of children. His job, middle management. His car, mid-size sedan. His favorite ice cream flavor, vanilla.

James was forgettable in every way, another person walking down the street. It's not that he was a boring person, or tepid. He was wild and carousing in college. He had his sights set on being a corporate pirate. He dreamed of the 80's bonds brokers like it was a decade of fiction rather than fact.

But after his first child, he lost his carelessness. Seeing his little daughter's newborn hand curl around his index finger, he couldn't see the point in all the risk and all the danger. Safe bets. Sure things. Slow and steady. He couldn't put her bright future in peril. He'd be careful. He'd look both ways. He'd measure twice and cut once.

So when he had his first heart attack at 40, he was as shocked as everyone else. He hadn't even seen it coming. Indigestion, he kept telling the doctors. Indigestion, he told the cardiologist. He left the hospital with 2 stents and some Prilosec.

His second child, a perfect little boy, only cemented his resolve to shape up. He didn't even eat spicy food. He took up jogging. He did sit ups. So he was as surprised as anyone when his leg turned blue and painful. While out for a jog, suddenly his leg was weak and pain ran up and down like it was being torn open. He fell to the ground and that was the last step he'd ever take. He smacked his head, and it was blissful unconsciousness till another jogger found him.

In the ER, they took one look and sent him upstairs. He had a procedure done to remove the clot that blocked the blood flow to his leg, but it was a touch too late, the surgeons said. His foot was still red and painful, and angry. It looked fierce. And then it turned purple, and James didn't remember anything after that. He'd gone for surgery 4 times, each time removing more and more of his leg, till even the surgeon couldn't stare at him.

And as they disarticulated his femur from his hip, they knew he'd never see morning, but to look as his wife and 2 children and tell them James, a man of 46 years, who had only been to the ER once before in his life, would die, it was too much. And so James died from gangrene due to ischemia from arterial thromboembolic disease.

About this site

  • This is an ancillary blog to the Incidental Findings blog. It is inspired by patients I have met in the course of my practice. However, this site is entirely fictitious. None of the details including names, ages, diagnoses, or situations are real. No HIPAA protected health information is included. These descriptions are not factual. They are fiction. As with my other blogs, this site is anonymous.
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