Patients With Multiple Problems Sometimes Have Only One Diagnosis

A ten year old shopping list of ailments

The forty year old man just seemed to have too many things wrong with him. I had first met him a couple of years ago with a monthlong history of bowel trouble. He also suffered from itching and rashes, which he managed fairly well with cetirizine, famotidine and diphenhydramine. He had no obvious allergy triggers in his environment and declined allergy testing. All the testing for his bowels turned out negative and he didn’t turn up in my schedule again until a month or so ago.

This time he came in because his insurance company made him. He had been to the emergency room several times for back and abdominal pain and his Maine Medicaid seemed to think he was wasting their money.

As I listened to him, he told me he was having random attacks of abdominal pain, chronic back pain and other aches that he described as bone pain. He was also itching all over again. The famotidine had disappeared from his medication list, and it was now in scarce supply after the competing histamine 2 blocker ranitidine was pulled off the market.

There was however a new medication, a drug to treat low blood pressure. He told me he had seen a cardiologist for this on referral from another primary care doctor after an emergency room visit for fainting spells.

I pulled the ER reports off Maine Health Infonet and glanced through them as he talked about how poorly he felt, I saw nonspecific histories, normal exams and unremarkable routine bloodwork.

My eyes stopped as I read the non-acute findings in his abdominal CT report from a month before our visit. Every vertebra in his spine looked abnormal, “sclerotic” in the radiologist’s words. He even listed conditions that could make bones look like that. One of them was mastocytosis.

It was an instant explanation to years of symptoms, even the low blood pressure, which I didn’t know, but once I read up on mastocytosis, it was on the long list of possible symptoms.

The ER doctor who was looking for a cause for abdominal pain did not spend any time wondering why the spine looked abnormal because it seemed irrelevant to the patient’s presenting symptom. Good thing the insurance company told the patient to see a generalist, who could look over the whole situation and in this case find the unifying diagnosis that was already suggested by a radiologist who knew nothing of this man’s long and complicated medical history.

A rusted-up tin man

Another man, much older, had over the course of a few months seen an orthopedist for shoulder pain and carpal tunnel syndrome and soon after that also gone to the hospital by ambulance for back pain with no real diagnosis when all was said and done. He had already had EMGs of his arms and a cortisone shot to his worst shoulder.

The other day I saw him for a painful swollen wrist and hand.

I asked him to raise his arms, which he did with great pain and effort without reaching horizontal, and to pull his knees up so as to flex his hips, which he couldn’t do at all. In fact, when I asked him to get up from his chair, he almost couldn’t do it; he moved like a rusted-up tin man.

I made sure he had no headache, visual disturbance or temporal artery tenderness before I reassured him that was he has is usually not serious and eminently treatable with pills, but it may take a year or two.

I ordered a sedimentation rate and CRP and prescribed a starting dose of prednisone for his polymyalgia rheumatica. The whole visit didn’t take ten minutes.

Internal and external fire

I also remember the eleven year old girl from out of state who moved here with severe asthma and a chronic rash over 90% of her body. She brought a bag full of creams, several pill bottles and a couple of inhalers. She had been treated by a big city allergist and a dermatologist with modest success. She had very few identified allergies.

Her records had not arrived. Her mother was frustrated at that and the girl was scratching herself as I pored over the prescription labels.

I took a deep breath and asked if she had ever been recommended any kind of elimination diet, like avoiding milk or gluten. The mother shook her head while the girl kept scratching herself.

“The fact that you have both asthma and eczema tells me your immune system is hyperactive, and there’s always a reason when that happens. I think one of the most overlooked causes of this is low level gluten sensitivity.”

The mother lit up. “I’m ready for anything”, she said.

“Okay, this isn’t easy, but give it 3-4 weeks. There’s gluten in anything made from wheat, rye, oats and barley, spelt and some other grains. You can google what foods contain these, like bread, crackers, pasta, fake meat and so on.”

I added, “I would also like to make your Symbicort inhaler stronger. Other than that keep all your medicines the same for now”.

Our followup visit was a televisit because of the Coronavirus lockdown. The mother panned her iPhone over the girl’s normal looking skin on her neck, face and arms down to her legs, which had a very modest rash and very dry skin. I prescribed a different topical for that.

In other words:

Sometimes elusive diagnoses reveal themselves in mere minutes

8 Responses to “Patients With Multiple Problems Sometimes Have Only One Diagnosis”

  1. 1 Spring Texan April 17, 2020 at 8:26 am

    Three great stories! Must have been a huge relief to each patient.

  2. 2 Georgia April 17, 2020 at 5:43 pm

    I wish you lived in my town! 🌻

  3. 3 Lou April 17, 2020 at 10:06 pm

    Re: case no. three, what is ” fake meat and so on . ” ?

  4. 5 K.N. Klein MD April 23, 2020 at 2:40 pm

    Excellent contribution! I did have one question re: “There’s gluten in anything made from wheat, rye, OATS (?) and barley, spelt and some other grains.” From my readings, I had the impression that oats do not have gluten. I know that General Mills specifically reformulated Cheerios to be completely gluten-free. Thanks for your excellent insight in the above 3 cases.

    • 6 acountrydoctorwrites April 23, 2020 at 8:22 pm

      This is complicated. Oats contain prolamins, apparently somewhat different from what you get in traditional gluten rich grains. Oat prolamins have been linked to leaky gut, although not celiac disease. The other issue is contamination/impurities from other grains in the field or in shipping, storage and handling of oats.

  5. 8 Dr. Nam May 18, 2020 at 11:07 pm

    This is undoubtedly the best article I read.
    Most doctors nowadays doesn’t look at the patient as a whole.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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