A Country Doctor Writes:

Ruth grew up in Alabama and ended up in northern Maine last year. We still don’t have her medical records, but she says she was diagnosed with Crohn’s disease when she was a teenager. She has had six months of constant abdominal pain that gets worse when she eats. She seldom has diarrhea but sometimes feels constipated. She often has dry heaves and sometimes vomits.

Her bloodwork is normal and the CT scan that was done in our emergency room had only mild signs of thickened wall of her colon. Her upper and lower endoscopes had very modest abnormalities with nonspecific findings on biopsies.

She has seen a gastroenterologist downstate and is waiting to have an MRI of her small intestine.

Meanwhile, her constant abdominal pain is keeping her from holding down her new job. Hydrocodone has helped her, but that was a stopgap measure from one of her emergency room visits. Now the hospital doctors have labeled her a drug seeker.

As I listened to her story and watched her healthy appearance I began to wonder.

“Has your weight changed during all of this?” I asked.

“Not really.”

“And you have no blood or mucous in your stool?”

“No.”

“And you’re in pain every single day?”

“Just about.”

“And this started when you left Alabama? Was that a stressful move, a stressful time?”

“It was huge. And I’m still stressed out. I mean I can’t work and I’m not making any money. Does that matter?”

“I don’t know, I’m just looking for clues…”

I went over what lab tests had been done. Her inflammatory markers were only slightly elevated.

I had asked her to avoid milk and gluten containing foods when I first met her. She told me that made no difference.

The only symptom she has, really, is constant pain, I thought to myself. What if this is functional, an upregulation of pain signaling – the intestinal equivalent of fibromyalgia?

I have been vaguely aware of this condition, this scenario, but have no experience treating it. A quick search suggests the only treatment options are psychological and lifestyle interventions.

If this is neuropathic, would medications like amitriptyline or gabapentin or duloxetine work? Could they replace her hydrocodone?

She was willing to try.

A few days later she told me her nights are pain free on 10 mg of amitriptyline. But she’s too tired to take that medication during the day.

So, while the downstate gastroenterologists pursue their testing for where there might be physical disease pockets, I am looking in a different direction. They aren’t ready to do that yet and they may never be. Functional conditions receive little attention in medically underserved areas.

A Gut Feeling: Could This Case Really Be That Simple?

Ned is about my age. He came to see me about a year ago with swelling of one leg.

A few weeks after a steroid injection into his right hip, he noticed a gradual swelling of that leg. The hip felt fine. And Ned felt fine in general.

I examined him carefully and ordered what I think of as the usual tests when one leg is swollen and the other one isn’t.

Routine bloodwork and cardiac exam, venous Doppler of his leg, CT scan of his abdomen and pelvis were all normal. The orthopedic folks ordered an MRI of his swollen thigh. This showed the swelling of lymphedema but nothing else.

He got a compression stocking and carried on with his usual work and leisure activities.

Last month he got another steroid injection to the hip. A few weeks later, his lymphedema was almost gone.

I have not found anything like it in my search for answers. Has anyone else seen or heard about transient unilateral lymphedema, related to steroid injection or not?

One more instance of me confessing to my patient:

“I just don’t know.”

In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.

This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?

Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.

In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.

Seemingly simple things can sometimes be disasters waiting to happen. Nurse visits are not billable, only the dipstick urine test is in my first example. But the malpractice payout could be bigger than for a missed diagnosis made by a thorough clinician in good faith – if there was little clinical history and no physical exam done, not even eye contact between patient and treating physician.

Consider this analogy: How much less is a meal at the takeout window than inside the restaurant? The cost is usually the same and it certainly isn’t free.

A Happy Meal is a Happy Meal, no matter where or how you receive it. Diagnosis and treatment are not defined by their setting or visit charge.

Our receptionist asked: “Do you want your 10 o’clock to reschedule? He has a runny nose, a cough and muscle aches”. He failed some of the Covid screening questions.

“Well, he has allergies, chronic bronchitis and fibromyalgia. If he’s worse than usual, reschedule, but if he’s the same as always, I’ll see him”, I answered.

Mr. Swift’s wife told me he has diarrhea ten minutes after every meal, sometimes even fecal incontinence. When I asked how long that had been going on, she said two years, ever since his colon resection. And yes, the surgeons knew about it. The Swifts just never mentioned it to me.

“How long have you had these headaches?” I asked Randy Blake. “A while”, he answered. “Ballpark? A week, a month, a year?” I asked. “Maybe two or three years” was his reassuring answer. Not that it couldn’t be something serious, but it certainly wasn’t a fast moving disease.

It is striking, how often I as a physician am presented with a symptom without any information about its duration, speed of onset or progression. But that, the time factor, is usually the most important part of a case history.

Our bodies tend to be in a fairly steady state: Our weight, energy level, appetite, elimination habits and even our mood tend to vary only within a certain range. The more things deviate from that typical range and the faster this occurs, the more aggressively we tend to pursue an explanation.

A typical example of this is the kind of patient who comes in for a routine visit, 15-30 minutes at most, and mentions more than half a dozen symptoms just to be sure they’re not serious. One patient I had even said “just so it’s in my record”. Taken the wrong (?) way, that could even be seen as building a case against me in case one of those symptoms later turned out to be something serious that I overlooked.

Think of this as one of those sets of near-identical pictures where you have to spot the difference. That’s usually an easier task than finding something wrong with one single picture; our brains are wired to compare, and that’s easier with a real set of pictures than one faulty picture we have to compare with our internal vision of what things should look like.

Also think of this as considering the inevitability of age related changes. If someone seems to age more rapidly than we are used to, look for disease. Graying hair in a middle aged person is expected, but in a twenty year old it is very unusual. (That, by the way, is how I explain osteoporosis, T-score and Z-score to my patients.)

Timing is everything.

Ron Beck has a bad back. Sometimes he gets a bout of sciatica. It usually gets better after a week of prednisone.

Over a three day weekend, Ron went to the emergency room twice. The first time he got a shot of Toradol that did little for his pain. The second time, he got X-rays, some basic lab work and a prescription for prednisone and an urgent message for me to order an updated MRI as soon as possible. That message reached me late morning.

I called him up to see how he was doing. He was still in a great deal of pain and his leg had given out under him. But his leg did not feel numb, his back did not hurt, even with coughing, and he had full control of his urine and bowels. And then he told me his toes were blue.

I told him to come right over. His wife drove him.

On exam, his left leg seemed a little cool. His toes were indeed slightly bluish. I could not feel a pulse on top of his foot, at his ankle or even behind his knee. I listened for a long time with my pocket Doppler. There was no pulse.

I have seen a couple of cases of acute limb ischemia where the patient was in a wheelchair, writhing in agony. Ron was uncomfortable but not in agony. And this was day four of his leg pain.

“I’m worried that you’re having a vascular emergency that will need emergency surgery in Bangor. You will need a CT scan of your aorta and the blood vessels to your legs. So I want to send you to the hospital by ambulance”, I said.

“Anything, Doc”, he answered as his wife stroked his hand.

The staff called 911 and I called the emergency room. I told the doctor on duty what was going on.

“Well, if that’s what’s going on”, he said, “you’re better off sending him down the road to Mountainview Hospital, because our scanner is down and may be for the rest of the day.”

“Will you be medical control and order the crew to give him some analgesia on the way”, I asked.

“You’ve got it, we’ll keep him comfy on the way.”

A few hours went by.

“Look at this”, Autumn said as she handed me Ron’s report from the Mountainview ER.

The note said Ron had a palpable pulse on his left foot with good capillary refill. They did an ultrasound to rule out a deep vein thrombosis and sent him home. “Needs urgent lumbar MRI”, it ended.

“How are you feeling”, I asked him on the phone.

“Better, whatever they gave me finally helped the pain fairly well”, he answered.

“I’m still worried about your circulation”, I told him. “Let me see if I can get a CT scan anywhere.”

My hospital’s scanner was still down. Mountainview had no openings until the following week and neither did the only other hospital within 50 miles of us.

I called the vascular surgery office in Bangor and was able to speak to one of their doctors.

“I’ve never seen limb ischemia this outdrawn before, but I’m sure that’s what he has”, I said.

“Well, he’s had this for several days now, why don’t you just have him see me here in our clinic first thing tomorrow morning. We’ll do some noninvasive studies and take it from there.”

His pulse volume recordings were flatlined and his CT showed critical iliac stenosis. He had surgery and his limb was saved. I reported the case to the Chief Medical Officer of Mountainview Hospital.

Sometimes when you palpate for a pulse you can feel your own instead. And sometimes when examining a patient you find what you expect to find. A man with recurrent sciatica might be just another episode of the same thing. And an older doctor in a small rural clinic may just be an overreacting alarmist, looking for Zebras. But not this time.