Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, April 20, 2007

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:
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.


At Fri Apr 20, 09:54:00 PM, Anonymous Anonymous said...

Excellent post! I was fooled and am not embarrassed to admit it.

db (of Medrants)

At Sat Apr 21, 05:18:00 AM, Blogger Dr Dork said...

Don't beat yourself up, Dino.

We all have 20/20 hindsight. It sounds quite atypical.

I always wonder about a lot of the clinical findings we place a lot of weight on in terms of sensitivity/specificity.

If you'd re-worded "right lower thoracic tenderness" as "upper right epigastric tenderness" even us dummkopfs would have got it.

these types of cases are of course no substitute for personal seeing/examining a case, but are always interesting - more, please !


At Sat Apr 21, 11:31:00 AM, Blogger SeaSpray said...

Hi Dino Doc - very interesting posts!

I am glad the mystery is solved and she is feeling so good now.

Maybe you could start some kind of a blogpsphere medical mystery game. If it takes hold, then maybe some other doctor bloggers might like to present something as well. It was interesting to read the other comments and even to offer my opinion, even tho ruled out. At least I know I wasn't totally off the mark in suggesting renal involvement - that it was at least a consideration.

I admire you for being humble enough to admit to being stumped with a dx - sign of good character - for sure. :)

At Sat Apr 21, 12:00:00 PM, Anonymous Anonymous said...

I like the ill fitting bra diagnosis better.

At Sun Apr 22, 03:37:00 AM, Anonymous Anonymous said...

Ulcer was my first thought.

Years ago, I saw exactly the same kind of pain in my grandmother, who had been complaining of back pain for years. In her case, it was a 6 cm-wide benign gastric ulcer, diagnosed only after a melena.

At Sun Apr 22, 03:42:00 AM, Anonymous Anonymous said...

By the way, everybody (including her) thought it was her spine, since she was severely cyphoscoliotic.

At Sun Apr 22, 06:55:00 PM, Blogger Red Rabbit said...

Great teaching tool, Dino! Makes me sort of able to pretend I am studying (like I ought to be).

At Thu Apr 26, 10:52:00 PM, Anonymous Anonymous said...

Hey nice blog you got.

I just finished a page on Pain Killer Addiction.

It's meant to help those currently addicted and those still struggling with pain killer addiction and other opiate addictions.

Well I hope you like my site, and I'll stop by your blog again.


At Mon May 26, 04:33:00 AM, Anonymous Anonymous said...

oopps I am just now seeing this post and I dont think this is my problem either! DAMN...... SORRY!


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