Saturday, 26 July 2008

Common things are common

From time to time I have asked Martha whether she would like to contribute to this blog. She is self-effacing and has always demurred until recently, when she sent me an extract from her reflective diary. I have embellished it a little with a few thoughts of my own and it is written “as from” me, but most of it is Martha's work.
We have recently had two patients with what feel like rather tardy diagnoses of common chronic diseases. In retrospect the main problem was that not only did they fail to tell us the right story - we all rely quite rightly on the history to point us to these diagnoses - but they actually told us the wrong story for the diagnosis and we could not make sense of it. Both also developed completely unrelated problems during the early stages of the chronic disease which required operations, and this perhaps led us to focus our attention elsewhere for a while.

The first was an elderly, solitary and extremely anxious woman who on a windy day had an encounter with a dustbin lid which hit her on the face. Following this she developed a trembling of the jaw which was not very noticeable at first. The story was reiterated forcefully during a number of consultations over a period of time, and she focussed the discussion on whether she could have damaged a nerve or whether it was one of those tremors which can develop in old age, and so on.

To his credit, the partner who eventually referred her to a neurologist considered the correct diagnosis (which was Parkinson's Disease) but thought it unlikely and said so in his referral letter. The tale has an interesting sequel, because when she attended the outpatients clinic the consultant exclaimed “Parkinson's” as she walked through the door. (No doubt he had discussed the referral letter with the medical students sitting with him before she entered.) At first our patient refused to accept the diagnosis because it was made before the consultant had taken a history or examined her. I had to explain that he already knew the history from the referral letter, and that with his great experience he had been able to make the diagnosis by observing her gait and lack of facial expression. No doubt he called it out to impress the medical students, but he did not impress our patient.

The second patient was an African man who had quite bad asthma and atopy to start with, and then complained that his temples and lips swelled up after eating. Indeed, this had been witnessed by the interpreter who sometimes accompanied him. Then he started to describe slurring of speech and fatiguability. In addition he had suffered from a number of other pains and symptoms for several years, none of which we could take away for him, and all this was getting him down. This felt like a story about some odd allergic presentation, although the fatiguability was a little suggestive of myasthenia gravis. We did a number of blood tests, but not the crucial one.

There were a number of confounding factors which prevented us from seeing things clearly. As mentioned above, he had a concurrent illness which required an operation. His English is not good and interpreters were not always available. Perhaps because he found it difficult to communicate with our receptionists he usually saw a different doctor each time he attended. And in his distress he also consulted a doctor abroad and talked to a relative who is a hospital doctor in another part of this country. I'm afraid that I was not impressed by his relative's suggestions which included a short Synacthen test. It is true that he had been prescribed a week's course of prednisolone six months earlier, but I was certain that this could not have caused adrenal failure. In any case we cannot arrange this test in general practice so I ignored the recommendations and we continued to wait for his outpatient appointment.

Fortunately Martha decided to review his case and saw that although we had done many blood tests we had not checked his thyroid function. This had been one of the tests suggested by his relative. His free T4 was about 3 and his TSH was off the scale, indicating profound hypothyroidism. We cancelled his outpatient appointment, started him on a low dose of levothyroxine to be increased slowly and cautiously, and he is starting to feel a lot better.

What conclusion can we draw? Perhaps this: that patients can only tell us how they experience their symptoms. If they add up to a strange story it is more likely to be an atypical presentation of something common than a hens' teeth job.

6 comments:

sara said...

Off topic, sort of, but today I performed my first Synacthen test. It was normal.

Good stories, as usual.

Gimlet said...

My immediate thought on this is that the African gentleman's relative presumably spoke his language and they discussed all his symptoms in that language. So much can be 'lost in translation', even supposing that the translation is good in the first place!

Ms Medic said...

Keep reminding me that common things are common. Rather to our disadvantage, rare things are disturbingly common at the central London teaching hospitals, but I fear they will not be so at my new DGH!

gibney said...

Just out of interest - why aren't people presenting as depressed automatically screened for physical causes of depression eg. anaemia, thyroid disease etc.? Is it due to the expense of testing?

gibney said...

Just out of interest - why aren't people presenting as depressed automatically screened for physical causes of depression eg. anaemia, thyroid disease etc.? Is it due to the expense of testing?

PhD scientist said...

Of course it can happen in tertiary acure care centres too...

I heard the following story from an intensivist friend at a very posh Southern English academic hospital. The patient looked like a classic appendicitis - except that the site of maximal pain was in the wrong place.

A large bevy of eminent consultants and even a couple of Professors of Intensive Care swapped possible hen's tooth diagnoses, getting into ever rarer conditions, and musing about case reports, while my friend (schooled in a rather more pragmatic Northern environment) kept muttering something like "atypical location of maximal pain does not rule out the diagnosis".

When the scan was done, lo and behold, appendicitis with an unusual anatomically-located appendix. The patient made a full recovery, but no case reports were penned.