Clinical Case (Part 2)

(Part 1 is here.)

Edited: This post was written immediately after Part 1, and held pending the comment response. ie, these are the things (in roughly this order) that I was thinking of.

To re-cap: healthy, active 67 -year-old with worsening back pain radiating around the right side over several months.

When I first saw her, things that occurred to me were:

• Incipient herpes zoster, though that idea fell by the wayside as time went on without any rash breaking out.
• Kidney stone/renal colic
• Assorted musculoskeletal etiologies; possibly unrecognized acute injury/repetitive motion injury from tennis

As she failed to respond to conservative therapy and I became more impressed with the abdominal/visceral component of the pain, my differential expanded:

• Gall stones/biliary colic
• Pancreatitis (or other pancreatic pathology, including possibly carcinoma)
  
• Abdominal aortic aneurysm (less likely in a female never-smoker)

When she went to the ER, they did a CT which showed a "penetrating" duodenal ulcer. (If you click on that link, you'll see this:)

The most common symptom of a peptic ulcer is pain.

Not perforated (no free air) and no bleeding seen at endoscopy. But her biopsy was positive for H. pylori infection, and she responded magnificently to acid suppression and antibiotic eradication therapy.

When I saw her post-hospitalization, she felt fantastic. She told me, "I didn't realize how much chronic pain I was in. I didn't remember what it was like to be pain-free." (It had been about six months from the time she had first noticed the pain.) Her blood pressure was even back to normal.

Here's the thing: I completely missed the diagnosis. I didn't even think of ulcer disease. I probably should have, but I didn't. Apologies for the red herring in the presentation, but ultrasound wasn't even the right test.

Most of the time in the blogosphere, clinical case presentations like this are meant as a way for the authors to show off their diagnostic acumen, or share stories of bizarre or unusual cases. Stories that show how smart we are, despite our modest demurrals that we're only human, and of course we make mistakes. Somehow, though, those are never the cases that (voluntarily) see the light of day. And so I offer to show rather than just tell of my all-too-human fallibility. For what it's worth, I'll be quicker to think of ulcer disease from now on. That's why it's called "practicing" medicine.

Edited to add this after the comment response:

Kudos to Red Rabbit. Well done!

Honorable mention to RM.

Regarding Sid's surgical "organ-elimination" approach to diagnosis: Sid, remind me not to consult with you about headaches.

I admit I'm surprised at the response. I was certain all you internists with your superior diagnostic acumen would zero right in on it. [No sarcasm intended; sincerity can be tricky to convey in blogging, but that is what I am trying to express.] Although it might seem I should feel less stupid for my failure to consider peptic ulcer disease given everyone else's difficulties coming up with it, it doesn't really change anything. Case presentations in this format are truly a far cry from actually talking with and examining a patient. I continue to feel strongly that many, if not most, of the clinicians who so graciously participated would have in fact asked different questions, elicited different answers, and/or interpreted the patient's presentation differently, coming up with the right answer sooner, and thus sparing the lady a fair amount of pain, had they been in the actual position of caring for this patient.