Thursday, 15 September 2011

A patient for Dr House

A patient for Dr House

Today on the ward round I met a patient who had a confusing set of symptoms and had been given in my opinion a very unsatisfactory diagnosis. I struggled to work out the patient’s exact symptoms and their duration due to most the discussion about her being in Swahili and although I later tried to read through her notes (v.vague) and take her history, neither the patient nor her family spoke much English so it was pretty hard. But the gist of what I think was her history is as follows:
1. Chronic headaches which she presented with 3 weeks ago but had been suffering from them for a long time and they had been getting worse.
2. Chest pain for at least 3 weeks - patient gestured at her sternum so I think it is midline chest pain, she also seemed to indicate the pain was worse on swallowing and then the pain went down, but this was all in gestures so not too certain!
3. Some confusing history of abdo pain,?fever and possibly some diarrhoea and vomiting over past 3 weeks.
4. 5 day history of bilateral leg weakness and some weakness to right hand.

Past history: 1 year ago was treated apparently successfully for ?peptic ulcer disease.

The doctor’s impression?
The patient had been in and out of hospital a few times over the last 3 weeks and had already been treated/ tested for the standard combo of ?malaria, ?typhoid, ?TB, ?HIV plus had been given a chest x ray. As the x-ray was clear and the patient was still ill even after receiving treatment the doctor concluded that her symptoms were "psychological and due to hysteria not a physical condition". The main reasoning he gave to me (beyond exclusion of the above diseases)? "The woman has no husband or children". Whaaaaaaaaaaat! So being single and childless = psychologically ill... Well better diagnose me along with her then! (And they probably would too - some of the midwives have already told me I am crazy when I have said after they questioned that I don't currently have a boyfriend!).

Psychological causes of symptoms in England are supposed to only be diagnosed when all possible/probable organic causes (physical illnesses) have been excluded. Here they definitely have not been, I’m aware they don’t have the facilities to diagnose all possible organic causes of her symptoms but I felt there were still some causes they could investigate that they had not considered. I was writing the notes for this patient and so under “Impression” should have written mental illness as this is what the doctor thought and wanted noted. Well I couldn’t very well not state his impression as I am definitely not in the position to do that but I did change the wording very subtly to “doctors impression”. A small act of defiance perhaps, but not one that would be noticed or was aimed to be, it’s just I wouldn’t feel happy signing my name at the bottom of those notes otherwise as that would imply mental illness was my impression of the patient.

My actual impression/ differential diagnoses?
1. Recurrence of peptic ulcer causing chest pain plus anaemia due to blood loss as a result of the ulcer (which would potentially explain the leg weakness). The patient had not reported vomiting blood but it could be an ulcer lower down so the blood may be being lost through stool instead. The headaches could also be connected in that she may have been taking analgesia such as NSAIDs (eg nurofen, aspirin) for her headaches which can cause ulcers if taken for prolonged amounts of time.

2. Some form of endocrine (hormonal) disorder, possibly secondary to a form of cancer/ cancer metastases which may in itself explain some of her symptoms such as the pain on swallowing. She is quite young to have cancer though as she is only 27. Sadly not impossible though but hopefully not.

3. Electrolyte imbalance. Again this tends to only explain some of her symptoms (particularly the leg paralysis) but can again be secondary to something else like cancer metastases which could explain the rest.

4. Lupus... Ok I'm clutching at straws a bit, but it is a genuine possibility albeit an unlikely one. The reason it always over appears in programs such as house is that it can present with a wide range of symptoms. Therefore if you have a patient with a weird mix of problems it can be a tempting diagnosis in that it neatly explains all of them! Lupus is more common in women and most common in this patients age group soooo it could be a possible differential. She didn't have any of the clear cut signs of lupus though such as a butterfly shaped rash on her face - whilst only 50% of lupus sufferers have this rash, it does mean she is less likely to have this condition.

5. Somatoform disorder. It is a possibility, but I still stand by it being a less likely one than the above possible causes (and undoubtedly there are likely to be other possible causes that I either have not considered or have mistakenly discounted). And as I said before, it a diagnosis that should only be considered once all other possible causes have been excluded WHICH THEY HAVEN'T!!! Okay.. Rant over... For now :P

Well will try and suggest my differentials to one of the senior doctors after tomorrow mornings meeting and see what they say. Will attempt to phrase it in a kind of confused student wanting teaching/ explaining way in an attempt to minimise irritating anyone. I'm not sure what else I can do and I really don't want to do this but if I don't do anything then I don't think anyone will look further into possible physical causes of her illness. Maybe they won't anyway but at least I will have tried.

Halfadoc x


  1. Any chance it could be Chrohn's disease?

  2. Hmm I don't think so, that would only really explain point 3 and that wasn't really her main symptoms. Crohns can occasionally effect the oesophagus i think so could then explain point 2 but its quite rare for crohns to effect there so unlikely. Also it would be quite unlikely that she wouldn't have had some kind of abdomen symptoms before this episode if it was crohns I think.

    Maybe I am missing something tho, I don't know all that much about crohns, only the core stuff; what makes you feel it could be crohns?