If 13 Clinicians Can't Agree on Your Diagnosis, You've Got a Problem!
Thirteen clinicians, six of whom were chairpersons at major academic medical centers.
One patient, a 38-year-old, left-handed, 5-foot, 1-inch Caucasian women who worked as a nurse and whose husband was a general practitioner.
Three and a half years and one pain specialist later: diagnosis, treatment, recovery.
The “take home” message: clinicians should evaluate patients using binoculars “rather than monocular specialty vision,” said Gary W. Jay, MD, FAAPM, Chief Medical Officer, RAPID Pharmaceuticals, Rockville, Maryland, in presenting this clinical conundrum, one of his own cases from the mid-1990s.
The patient had gone through a full-term pregnancy and delivered a son. Three months later, she experienced extreme fatigue. Her primary care provider sent her to an endocrinologist. Her TSH was >10 mU/L. She was diagnosed with hypothyroidism, not uncommon after pregnancy, and started on levothyroxine sodium; later, liothyronine sodium was added.
One month later, she was awakened at night with severe bilateral otalgia. After getting out of bed, she was so dizzy she fell onto the floor; she was also extremely nauseated. Her husband helped her back to bed and brought her ASA and water, but she couldn't keep it down. Over the next several weeks, she became bedbound.
Doctor #1: Her Primary Care Provider (an Internal Medicine Specialist)
Endocrine status fine on medications. Symptoms included severe bilateral otalgia, dizziness, and nausea. Mild bradycardia detected (normal for her). Blood work WNL. Diagnosis: unknown. She remained bedbound and was referred to a local ENT.
Doctor #2: ENT
Diagnosis: vertigo of unknown etiology. A subsequent cerebral MRI with and without enhancement was negative. Referred to a neurologist.
Doctor #3: Local Neurologist
The patient had difficulty walking a straight line. Results of cold and warm calorics were “equivocal.” The plan: evaluation by another local ENT.
Doctor #4: Local ENT Affiliated with Local University Medical Center
No hearing deficits detected. The diagnosis: autoimmune disorder of bilateral inner ears. The recommendation: methotrexate and prednisone. The patient, at her husband's urging, refused.
Doctor #5: General Surgeon at PCP's Recommendation, Specialized in GI, to Look at Her Nausea
The diagnosis: cholecystitis; the plan, cholecystectomy. The patient remained bedbound, both from healing from her cholecystectomy and continued severe bilateral otalgia and difficulty walking secondary to dizziness.
The patient is now 15 months from onset of symptoms.
Doctor #6: Chairman, Department of Otolaryngology in a Midwest Medical Center
A resident takes the patient's history and examination. The chairman says her symptoms “made no sense,” diagnoses her with hysteria, and tells her to go back to work.
Her husband had been doing his best to follow the rule: “don't treat your family.” However, now angry, he began to call friends.