Medicine For People!

February 2014: Occupation:  Medical Detective

February Newsletter

Occupation:  Medical Detective

The Wrong Diagnosis

Not that long ago, a physician could not reliably differentiate infected appendicitis from lymph tissue irritation in the right lower quadrant of the abdomen. As a result, about one appendectomy in ten was unnecessary. The prudent physician had told the family ahead of time that delay of surgery could allow an infected appendix to rupture, but that the diagnosis was only 90 percent certain.  The less thoughtful physician had to explain later that the lymph nodes were actually the problem.

Today, CT scans allow the surgeon to prevent those un-needed surgeries and the accompanying embarrassment.

The Downside of Technology

The downside of CT scans and other technology is that the physical examination of the patient gets less attention than it did. When we focus too much on an imaging study, we can do a disservice to healthy people as detailed in a previous newsletter. Just as we don't take to our bed when our skin develops age spots or wrinkles, neither should we doubt our ability to walk when our doctor tells us that an X-ray shows an aging joint.  Too often, though, people allow themselves to be influenced and unconsciously reduce their activity, further allowing their system to lose function.   In addition many doctors focus too much on laboratory testing, and we end up with millions of people on medications that treat only the lab numbers, not the person.

The best approach is to combine hands-on care with technological aids.  This newsletter gives examples of how that's done.  So, imagine you are in your doctor's office with an illness. How does the doctor decide what you need?

Patient History

First, we take what we call a history. When did symptoms begin? How often do they occur? Does abdominal pain occur before or after a bowel movement? In medical school we study what we call pathology, which is a catalog of the conditions the human frame is prone to and what symptoms these illnesses cause. Of course, the diseases don't read the textbook, and most of time the patterns will not fit perfectly.  Nonetheless, a history is always the first step in diagnosis.  In medical school, one of our professors told us that if we listened long enough, the patient would tell us what was wrong with them.  This turns out to be truer than it sounded.

Physical Examination

The second step is the physical examination, the major topic of this newsletter.

"Cold Normal"

Let me give you the example of Tim who came one day with a cough of two weeks duration. He had a fair degree of fatigue. He ached all over and just didn't feel good at all. When I examined Tim, his ears, his eyes, his throat, his lymph nodes, his heart – everything was normal. In fact, everything was "cold normal," the phrase of choice when you really have carefully looked at every single thing, even searching for some possible clue not in the textbook.

A Tiny Clue

One thing was different. When I listened to his lungs from the back, I could hear normal breath sounds everywhere except for an inch and a half just to the left side of his vertebral column at the lower third of his lung. In this region, there was less breath coming into the tissue. I could not hear the telltale rales of pneumonia, but there were one or two quiet rhonchi, a sound not uncommon in people who smoke or exercise too little. In addition, when I tapped on his back, the percussion note was more muted in that area than elsewhere on his chest. I checked for changes in fremitus (vibration in the chest wall), but no, there was no fremitus.

Probable Pneumonia

Tim, as is true of many of our patients, had no insurance. He was missing work, something he rarely did, and I suspected that he had pneumonia. I told him that many doctors would do an x-ray, but I saw no risk in waiting a couple of days to see if the diagnostic picture cleared. Furthermore, on more than a few similar occasions I had sent patients like Tim for an X-ray and had the radiologist telephone me back and say "there are some increased broncho-vesicular markings to the left of the vertebral column, not sure what's causing that, could be normal.  What did he look like when you examined him?"  The radiologists call this "asking for clinical correlation." In any event, I felt pretty confident to prescribe an antibiotic that day and see how the diagnostic picture cleared as time progressed.

When I saw him two days later, he felt considerably better. Laying my stethoscope to the lower part of the left lung just above the diaphragm now revealed numerous sounds indicative of pneumonia. Some of this was due to his improved hydration, and some to the passage of time. In any case the picture was now clear.

Flat on the Floor

Ralph was a patient whose diagnosis was even less clear at the start. He reported about a week of temperatures as high as 99.7.  The pain in various parts of his abdomen had been severe enough that he had spent more than a little time on the floor of his bedroom wondering if he should go to the emergency department. At the time the pain had started, he had been doing a good deal of heavy lifting.  He wondered if the pain was arising from a hernia or a pulled muscle in the abdominal wall.

Fifteen minutes of questions and answers gave no hints as to what might be wrong. His exam was similarly unrevealing.  He had little discomfort from pressing on the tense muscles. He did not have signs of peritoneal irritation.  I explained that were we in the emergency room, we would be doing a CT scan, and would he be agreeable to that today? Like Tim, he was uninsured and did not wish to spend the money. I prescribed some dietary measures, plenty of fluids, and a proton pump inhibitor. We obtained some lab work.

A Tender Point Identified

When Ralph returned two days later he felt a little better, but again had bouts of pain bad enough to entertain thoughts of the emergency department. His blood work was entirely normal except for an elevated neutrophil count. Increased neutrophils, the most common type of white blood cell, often indicate a bacterial infection. On exam that day he had one area of point tenderness in the right lower quadrant of his abdomen. This was not a random finding but occurred every time I pressed that particular point. Tensing the abdominal wall removed the tenderness.

These illustrations help show my thinking at this point.

 LargeIntestine Anatomy

Standard illustrations of the colon[1] show the sigmoid colon looping just above the rectum, which it usually does.   

Photo 2: Barium enema study after three months

No law, however, prevents the sigmoid colon from flopping over to the right side as shown here or in the X-ray above. [2]  I suspected Ralph had this variation of his anatomy, and that most likely that he had an infected diverticulum in this part of his sigmoid colon.[3]

Two days of antibiotics proved this assumption even more likely, because Ralph's fever disappeared and he felt much better. Once Ralph recovers entirely he'll get a barium enema to see if indeed he has diverticuli. Then we'll be better able to avoid further episodes and treat them more quickly should they occur.

Knowing the Patient

Tim and Ralph are both people I've had as patients for some time, which makes it easier for us to work together. I can better understand what their words are trying to convey. Ralph, for example, did not look at all acutely ill on either of his first two visits. But he told me had been on the floor thinking of going to the emergency department. I got the message without Ralph needing to go into high drama mode. I was able to do what he required for diagnosis without going overboard. Similarly with Tim. Rarely does he come to see me; when he said he was sick, I knew he was.

Sometimes You Need to Believe the Patient...

Two patients from Wisconsin come to mind. Tom was a 5' 6" unemployed musician with a stutter. He'd complained to his doctors that his erections weren't what they had been and maybe his testosterone was low. (Viagra was still in the future.) Knowing that most men with erectile dysfunction have normal levels of testosterone, they'd said that he'd just have to adjust to it.  He came and told me the story. Lengthy questioning revealed he had headaches, poor libido, loss of muscle strength, trouble holding his own in arguments with band members, all of which are symptoms of testosterone deficiency. We did the test and sure enough he was low. Lesson learned – resist the thought that your patient is crazy.  He may just know what he's talking about and make you look like the fool you are.

...and Sometimes You'd Better Use Your Head

Jane walked in one day with a strained expression on her face. She couldn't keep still, and kept rubbing her back with her hands. She seemed embarrassed and said "I know this is all my head, but my back hurts and I just can't stand it." Every other question that I asked to discover more about this pain was answered with "I'm just being a wuss; I've been under a lot of stress; I know this is all in my head." Well, all that was very enticing, but she didn't get into my office by accident. I went through her history and a careful physical exam. It didn't take long to get a urinalysis, see some blood in the urine, and figure out that she had a kidney stone. Strangely enough, she was still a little apologetic about the whole thing.  "I'm sorry, I didn't have an appointment." Straight out of Garrison Keillor's Lake Wobegon, Jane was hard not to like.

Balance is All

These stories show that laboratory tests and imaging studies may be wonderful adjuncts to medical care.  However, tests will not (in any imaginable future) replace the patient history and exam. People and their ailments, people's minds, bodies, and emotions are just too complex.

And yes, I know you didn't ask, but believe me, this is a fascinating job.


[1] Wikipedia





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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.