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