Diagnosing a disease can be challenging, especially when symptoms are common or non-specific. Knowing when you need to call in a specialist or gather more information is key to a proper diagnosis, and sadly is what failed in this case.

Ms W was a 19-year-old college student, studying to become a physical therapist when she began suffering from anxiety and depression. She began seeing her school’s counselor for help, but also went to her primary care physician, her pediatrician, because she was feeling run down. The pediatrician ordered blood work which showed elevated levels of liver enzymes, and the doctor diagnosed Ms W with mononucleosis.

A few months later, Ms W began experiencing changes in her personality as well as an increase in anxiety and depression. School was becoming increasingly difficult for her and talking to the school’s counselor was not helping. Her parents were worried, and suggested she see her doctor again. Ms W did, and the physician diagnosed her with anxiety and depression, and prescribed fluoxetine.

A year later, Ms W, now 20, was accepted into a physical therapy doctoral program. When she began suffering sporadic tremors in her right hand, she and her parents became concerned.  Ms W and her parents wanted to resolve whatever the issue was before she started the program. Ms W’s mother was particularly concerned about the tremor and accompanied Ms. W to her appointment with a new physician, Dr E.

Dr E was an internal medicine specialist working for a large health system. Ms W’s first visit was in December, when she came in with concerns about the hand tremor. Her mother expressed concern that Ms W might have a neurological problem.

After examining Ms W, Dr E noted in her records that the patient had “no tremors at rest, fine tremor on purpose.” The physician told the patient and her mother that Ms W’s issue was not neurological because “neurological issues should be constant and not come and go.” She diagnosed Ms W with anxiety and depression, increased the patient’s dose of antidepressant, and scheduled a follow-up visit for the next month. Ms W and her mother were relieved to hear the doctor’s assurance that Ms W did not have a neurological issue since her tremor was sporadic.

At the brief follow-up visit the next month, Ms W reported that the hand tremor was worsening. Dr E did not perform a neurological exam, nor did she refer Ms W to a neurologist. Rather, the physician advised Ms W to continue taking the antidepressant, and to come back 4 months later, in May, when school ended. Dr E believed stress from school was partially responsible for Ms W’s anxiety and depression, and that the patient was likely to improve once her senior year was done.

In the 4 months between appointments, however, Ms W’s condition continued to worsen. By the time she came in for her May appointment, her tremors were affecting her ability to write, she was constantly fidgeting, and she felt weak. Dr E noted the complaints, cut back on the patient’s dose of fluoxetine, but maintained that anxiety or possibly overmedication of fluoxetine was the cause.

In the weeks following her appointment Ms W emailed the physician about her worsening symptoms. She emailed Dr E that the tremors were increasing, and that she had muscle spasms, lack of balance, and could not write or cut her food. Dr E told her to stop taking the fluoxetine completely, and prescribed another antidepressant. Ms W kept emailing Dr E about symptoms, increasing fatigue and difficulty concentrating, but the physician attributed these to the stress of Ms W’s starting the doctorate program in early June.