Sunday, November 05, 2006

Differential Diagnosis

My on-call weekend as a community physiotherapist had been fairly quiet until I received a call from a case manager on Sunday morning asking me to see a lady who reportedly was unable to walk and needed a walker. She had been assessed at the emergency department three days earlier and was sent home with a diagnosis of sciatica to explain her severe leg pain. Her medical history included hypertension, smoking, COPD, peripheral vascular disease, anemia and spondylolisthesis.
Her very concerned daughter let me in and I took a quick history and then moved on to examine her extremities. Her one leg was completely ischemic, pulseless, blanched and cool, with no muscle movement and a darkening, swollen foot. Her pain was severe. I quickly called an ambulance and hoped that a vascular surgeon would be available this weekend to try and salvage her leg.

This is the second person this month I have seen with similar symptoms, both of them non-diabetic smokers, both told that their pain was related to arthritis of the spine. The other lady is now a below knee amputee, after two emergency vascular grafts failed to restore her circulation. She is in the hospital for rehabilitation but has not yet recovered from the shock of losing a limb so quickly.

Patients, especially older women, tend to minimize their symptoms and may not give the examining physician key facts in their history. The amputee had claudicating pain in her legs for years, but didn’t report it to anyone. Our emergency departments are in crisis in this community and in other parts of the province, with overworked doctors working extended shifts in very busy ER’s. My patient’s earlier hospital visit included a back Xray, which showed advanced arthritis, thus “explaining” her symptoms. Other possibilities were not considered after that.

We had a wonderful pediatrician for our children. He was a true clinician, doing thorough physical exams and histories before he ordered any tests. He took his time, and was always behind in his schedule, but I never minded, knowing we would not be rushed when it was our turn. In my experience, it seems that there are fewer of these doctors practicing now, with tests and procedures replacing a thorough physical exam. Other health practitioners need good assessment skills as well, and we can help educate our patients about their symptoms and physical findings.

postscript...the patient died in hospital shortly after admission
Photos from Venice, Italy, courtesy of my daughter

4 comments:

  1. In a way it makes me understand why so many of my friends who have been misdiagnosed are afraid to go to the doctor and emergency room. Especially since we (the patients) don't nessissarily remember all the pain we have had or we have learned to deal with the ones that exist to the point that we don't even realize they are there anymore.

    I understand there is a pressure on the doctors to get people in and out... But it makes the visit completely impersonal and it feels like the doctor isn't trying to understand you.

    I remember Dr Hood (my pediatrician when I was little) was always friends and took the time. I liked him very much. I want to find and adult doctor that way.

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  2. I hope you do find that special doctor. I work with some wonderful physicians, so I know they are out there. The more we understand about our own bodies, the more empowered we are to get good medical attention.

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  3. I managed a podiatry office for years, and my heart was broken so many times when patients would come in after living with neuropathy, decubitus ulcers, and the doctor would do all he could but the leg or the toes would eventually be removed. One guy in particular I remember: Beligerent, non-compliant DM who let his DOG lick and clean out his very deep ulcer on his foot. He tried to tell us repeatedly that "dog's mouths are way cleaner than a humans". And he lost his foot.
    sigh.
    So many of these amputations and costly re-vascularizations would have been avoided if they just would have sought treatment earlier.

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  4. Hi Susan...With so much health information available to the general public, it is hard to believe people can still be so misinformed. I know the types of people you describe exist as I have met them too. The doggy wound care is unique though!

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