No disrespect to Physical Therapists, but why are we always sent to PT no matter the symptoms? Non-muscular (vascular) Pain in the leg? PT.
And Rx for pain meds even after I explain I can't take them without negative side effects?!
8
So many questions. How recently had she been to the dentist? And did the dentist flag the bleeding gums? Is gastroparesis a real condition -- something diagnosed? And if so, did the doctor who diagnosed that condition initially pay attention to what the patient ate, making sure she got a balanced diet or took supplements? Like many in this series, it seems some of the doctors who first treated this patient missed signals.
15
All of these know it all comments about sending people to dietitians is very easy for armchair hypochondriacs but when someone comes in with internal bleeding that can’t be explained, the last thing you would think of is diet as a true diagnostician because of how rare any type of dietary deficiency really is in this day and age in a civilized country, especially when presented with tons of internal bleeding. For the presentation of rare symptoms you have to go through all of the logical not rare diagnosis first. That’s what a good diagnostician does.
6
Too me the surprising element in this story is the fact, that no doctor before inquired about the diet of the patient. Even for any half decent GP this is one of the basic first questions.
Our education in grade school should include balanced nutrition as a subject. Our health care system would be so much better off.
6
Seems like a lot of lay people would have immediately and so obviously arrived at the diagnosis of scurvy.
Can't focus when their office neighbor whistles to a song on the radio, but harnesses their inner Dr. House amidst the primal screams from the open-book pelvic fracture in the trauma bay.
Added Qualifications:
-Bought bitcoin at $5
-Bought Amazon stock in 1999
-Never missed a call in slow motion
-Never threw an interception in the same year as Tom Brady or with beer in hand
2
I thought everyone took a multi-vitamin. Amazing that anyone would fall to realize that the diet described by this patient would be deficient in so many essential nutrients.
8
And what about going in for a routine procedure and coming out sick? I have colonoscopies every five years (because of family history and polyps). For years, I had conscious sedation with no problem, but for the most recent procedure, I was given propofol and a pure oxygen cannula (I thought that the cannula was odd but was unprepared to object). By the time I got home, I had a fever and was coughing uncontrollably. The endoscopy clinic suggested that I go to an ER and get an Xray because I "could have pneumonia." I called my internal medicine doc, who asked some savvy questions and calmed me down. In two days, my fever went down on its own, but my coughing persisted for at least two weeks. A search of the internet revealed blogs full of complaints about the medically popular propofol/oxygen cannula technique, which apparently has a negative effect on an inordinately high number of patients. Why has this irritating and harmful procedure become so popular with gastroenterologists and anesthesiologists? Who is making money from this?
25
What does this have to do with the article?
7
I was actually far from impressed by the diagnosis of scurvy that was eventually made in this case (Diagnosis, March 4, 2018). This women had to become desperately ill before a nurse or a doctor took a good history. A past medical history would have revealed a stomach condition (described eventually) that would most certainly have uncovered the need for a very thorough diet history. Most lay people know that a lack of fruits and vegetables can result in any number of severe health problems.
As a nurse practitioner and former clinical instructor at the teaching hospital and academic institution that Dr Sanders is affiliated with, I would be appalled if my first year students did not explore this. Further, what ever health care provider diagnosed this condition (gastroparesis) who did not do nutritional teaching is failing his or her patient.
Worship at the alter of technology, electronic medical records and expensive tests is no substitute for a careful history and close listening. And as the caregiver of an aging (now deceased) parent at the same institution, I realize we are not teaching our young clinicians this very well.
34
I was going to excuse this oversight based on the fact that she may have gone to the ER each time - in which case, they may have just tried to stabilize her and then send her to another doctor for testing, and she may not have gone, or not have gone yet. But then I noticed that it said she spend 2 weeks in the hospital. So yeah, that's pretty bad that no one asked her about her diet or other conditions in that time, or if they did, that with all the other tests that were done, those weren't considered as good enough reasons to figure out her vitamin/mineral deficiencies.
3
This is at least the second time this column has covered scurvy. I remember the last time was an old woman with very specific dietary preferences.
2
I wonder about an eating disorder, given a very restrictive diet (and what sounds to be inadequate caloric intake) and her gastroparesis. Both are potential red flags for anorexia.
15
The unimaginable feeling of accomplishment when you save a person's life!
7
I complain about something to my doctor and she shrugs so I come home and Google
19
Please find another doctor. Look at the patient in this story
3
If only the lady had been a New Mexican. Green chile has all the Vitamin C (and A) anyone ever needs, and NOBODY in New Mexico goes without. Massachusetts residents presumably do get enough fish tho.
8
You’d think who ever diagnosed her gastric issue would have prescribed taking vitamin C.
33
It seems to me that scurvy could have been prevented if the medical practitioner who diagnosed her gastroparesis had provided adequate instruction on dietary needs (or had referred her to a registered dietitian) caused by that condition.
64
When I was diagnosed with celiac disease, I was pretty shocked to discover that this life-changing food -related diagnosis did not entitle me to even one covered visit with a nutritionist. We have good private insurance. So what sounds obvious may be economically out of reach.
41
The medical establishment farms sick people for profit. It is time for each person to assume responsibility for his or her own health, because the docs, for the most part, can't be bothered. They may know most of what there is to know, but the problem is they think they know everything.
They are captive indentured servants to insurers and big medical groups that only want to boost their turnover and maximize their profit. Don't believe a thing they say, until you check up on it yourself.
Any good guide to nutrition would have ID'ed this problem in five minutes. My copy of "Prescription for Nutritional Healing" by Phyllis Balch (2000 ISBN 1-58333-077-1), lists zinc multivitamins, vitamin C, and vitamin K/alfalfa as three VERY IMPORTANT supplements for bruising.
I have used this guide eighteen times, and it has completely resolved my problem in all of those situations. No substitute for an M.D. of course--just an insurance policy.
In two occasions, doctors were pushing costly, radical treatments. They were surprised, and both pronounced "a miracle". (I didn't tell them that I was second-guessing them.)
This didn't come to me in a dream. In the past twenty years, my PCP has prescribed four harmful drugs. (Lipitor, Atenelol, Flomax, and Ceftin) for no good reason.
I have also successfully questioned the recommendations of my dentist, and my wife and son's physicians, based on readily accessible empirical evidence. Thank heaven for the internet.
48
A few years ago, I rushed my husband to the ER because his leg had swollen up to double its size. The doctors at this very prestigious hospital did test after test and gave him steroids and a shot of adrenaline and they puzzled over the cause. We kept asking: could it have something to do with the hike we went on? They dismissed this. Two days later his condition had not improved. Finally a dermatologist was brought in and said "Allergy to poison oak."
If they had listened to us about the hike and put two and two together, it might have saved everyone, time, money, and worry. Sometimes, it's a few simple questions that can make all the difference.
72
I think the doctor who first diagnosed this woman with gastroparesis should have sent her to a dietician. They could have worked out a nutritionally adequate diet that she could tolerate and figured out if supplements would be necessary. This whole thing could have been prevented.
26
In my last year of medical school, my friend diagnosed scurvy in a patient with the classic "tea and toast" diet. In medical school, you learn classic presentations for something. For scurvy, it is bleeding gums, petichiae (the red spots on the leg), and corkscrew hairs. But, as they say, sometimes "the patients don't read the books." My guess is that the initial presentation wasn't so classic, and the physicians neglected to get a diet history on the first two visits. This isn't surprising, because we are all under incredible time pressure (I'm a medical intern now) and the presentation with an obvious cause for her bruise would not have prompted me to think about her diet. Here is to doing right the third time and being persistent.
49
If she was hospitalized, wasn't she supposed to get vitamin C enriched diet? something the hospital dietary department should address going forward.
Also, as Vitamin C is a water soluble vitamin which is not stored in body, a low vitamin C lab test could only reflect her recent vitamin C levels. Thereby making vitamin C level deficiency a possible cause but not definitive diagnosis.
Article highlights the importance of healthy diet which we all agree.
6
Interesting point about the hospital diet... but what she GOT and what she ATE was after all the root of the problem... Since citrus caused her heartburn, she wouldn't have eaten any. And not gotten any vitamin C subsequently. And gotten scurvy.
Hopefully AI will fill in the blanks left by humans.
6
This makes no sense. Why so many hospital visits? Did this person not consult a doctor? Wouldn't her own physician have run a few tests on her as the condition only worsened? Wouldn't basic blood work reveal the vitamin deficiency? Why on earth would anyone let bruising run up both legs and not seek non-emergency treatment as it progressed instead of waiting until it got so bad? The whole thing seems a bit odd.
20
Many people on this country don’t have their own physician they can go to. She may have had no insurance
14
No, basic blood tests would not reveal the vitamin C deficiency at all. They would only reveal the anemia.
A thorough history is what was needed to reveal this diagnosis. No invasive or expensive tests necessary.
Knowing how to take such a wide-ranging history (it requires thinking beyond the previously injured leg itself) is part of why physicians attend 4 years of medical school and a minimum of 3 years residency. Unfortunately, obtaining such a history takes far far longer than the 15 min per patient most physicians as granted by insurance companies. Thorough history taking is not reimbursed as it is not an invasive procedure or labs.
- an MD/MPH
6
We could tell it wasn’t the paint can because the color wasn’t revealed to us.
8
Modern Doctors may want to brush up on dietary sourced conditions such as Scurvy and Pellagra as they were once not uncommon among the underclass in the American South in the first half of the 20th century- not long ago. If Republicans keep savaging anti-poverty programs and help for others in need, it could quite possibly visit our nation again.
48
The Republican war against any social safety net and against women's rights is already causing epidemics: child abuse and neglect of children that people can't take care of, opiate abuse by people too far from the American dream. Flu and hepatitis running rampant; older people working with the public with one or more teeth missing - it's not far-fetched at all. Although the case described was unusual, I'm seeing more and more signs of a society collapsing. And I live in suburban Connecticut!
5
I am a reader of Patrick O'Brian's naval novels set in the 1800's. The doctor often felt that the "grog" consumed was unethical because the sailors consumed so much alcohol. The captain would explain that it was mixed with lemon juice, which the sailors would not consume on their own. On a couple of voyages sailors ran out of lemons and produced these same symptoms.
15
In more than one of those novels, when the ship ran out of fresh vegetables, the captain would make a great effort to find a place to land where the crew could buy or harvest fruits, veggies and greens. Some of their voyages lasted as long as two years--restocking fresh food along the way was vital to the health of the crew.
5
How could this woman avoid fruits and vegetables so completely? Did it not occur to her that she needs a balanced diet ?
25
Not long ago this same column (when it was called "Think Like a Doctor") had another case of scurvy, in a toddler with food aversions. It's likely that nutritional deficiencies are more frequent than is commonly thought, and unfortunately most doctors never ask and don't care what patients are eating. I hope this patient was sent to a dietician and got more advice than to just take a vitamin C supplement. Her diet must be extremely restrictive (note that you don't have to eat acidic citrus fruits to get vitamin C -- almost all vegetables have it, including potatoes.) Nutritional deficiencies rarely occur in isolation, and it's very likely she had multiple deficiencies besides Vitamin C.
27
Many insurance won’t cover a visit to a dietician. If she even had insurance
1
Even raw meat and fish have some Vitamin C. But cooking destroys it. Her tuna would have been canned, which is, of course, cooked.
Than do some reading. It is really not that difficult to eat healthy. Just can’t be lazy about that.
1
as I heard the story about the Royal Navy, it was limes that were mandated to avoid scurvy among the crews on long sea voyages.
and from this came the moniker "limey" when referring to Brits.
23
I teach prospective nursing students. Every year I describe the role of Vitamin C in forming connective tissue fibers, the history of scurvy, and discovery of its cure. And every year the only thing students remember is that English sailors are called limeys. Unfortunately, not every topic comes with such a fascinating story.
10
So, did C.R.P.S. explain the internal bleeding? An old boss of mine used to say, "Never assume anything, because it makes an ass out of u and me.".
Did the initial doctors learn the correct diagnosis and work on improving their diagnostic skills? C.R.P.S. sounds like zebras more than scurvy to me. Was she treated by only hospitalists in the hospital? Seems like anyone diagnosed with an eating related disease should also see a nutritionist to make sure to treat the patient in an holistic manner.
8
Nothing about her presentation except for pain is consistent with CRPS. I’m a doctor and I am flabbergasted and embarrassed by medical diagnosis like that. Our medical system keeps paying doctors less for more work and ungodly hours. The slots are being filled by poorly trained “doctors” from foreign medical schools or with nurses who undergo 2 years of medical training and who are well intentioned but not at the level of mds. Society gets what it pays for. Finance and tech attract the top people. Medicine no longer does.
8
Finance and tech - the suffocating embrace of our time. Each alone, not a worry. Marching in log step they present more harm than they do good (not discounting the latter, mind you).
1
There's nothing like having all the relevant information (and more importantly none of the extraneous stuff) set out in a few ordered paragraphs to make a diagnosis obvious.
I used to do advisory reports like that as part of my job. People would send me bulging files full of interview notes and original documents and other bits of information, and a cover letter saying "I don't know what to do next!" and I'd send them back an ordered summary of the relevant bits of what they'd sent me, at the end of which their next move would generally be obvious without any need for the specialist professional advice they'd thought they were asking for. It is much easier to diagnose anything if someone with better skills than you has picked out the information you need to know in advance and excluded the irrelevant stuff.
13
How do eskimos in Canada avoid scurvy? Their diet, particularly in winter, seems to consist almost exclusively of animal protein and fat, and has for centuries.
4
How do traditional Arctic peoples get vitamin C without vegetables?
My understanding is that they eat animal organs and tissues that are rich in needed vitamins.
7
Arctic/subarctic traditional diets include fresh plants during the summer, and raw meat or fish at all times. Fresh, raw meat does contain vitamin C; it is lost during most methods of cooking, drying or processing.
14
Preserved berries
Let’s remember that this article is a synopsis of what happened, not every detail.
So the mishmash of symptoms presented could have included all those mentioned in the article plus headaches, shoulder pain, stomach cramps, joint stiffness, sensitivity to light, rash and trouble sleeping.
Doctors have to separate out what is related to the main complaint and what is not.
Having said that, it does seem as though our medical system could use more generalists who can look at the big picture and solve the puzzle of what’s underneath rather than treating/prescribing for one symptom.
My migraines didn’t require a prescription; I needed a doc who looked at a bunch of things and found a food sensitivity. My foot pain didn’t need a cortisone shot; I needed a doc who recognized that foot pain together with some other subtle symptoms can point to a thyroid problem.
We patients have to be our own best advocates without becoming obsessive about our health. Ask your doctor to look for an underlying condition or disease rather than just accepting a prescription for one symptom. Do your own research online. Get copies of your test results and see what the abnormal results might indicate. Ask questions. See a naturopath or alternative doctor if your regular doctor isn’t finding answers.
14
The answer is so obvious. The punctuate hemorrhage, bleeding gums, easy bruising. It took the docs at Man’s Greatest Hospital so long to establish a diagnosis?!
7
Wonder whether she had any X-rays done of lower extremity and had any sign of scurvy in the bones?
This is a perfect example of plight of modern Medicine. Less time in history taking and detailed physical exam while more labs, more procedures and imaging, more specialist referral , polypharmacy etc are done as a result of an unfair reimbursement system for primary care physicians , who has pressure to see more and more patients to generate revenue.
2
Reminded me of the '30 Rock' episode in which the Alex Baldwin character is in the hospital with some un-diagnosed condition (if I recall), and deliriously starts shouting 'Lemon!, Lemon! ' (the Tina Fey character), and so the staff thinks he has scurvy.
3
The patient "didn't eat fruits and vegetables because they gave her wicked heartburn." As a layperson, it sounds to me like chronic acid reflux is this patient's real problem and wouldn't it be helpful to find out why instead of prescribing Vitamin C pills, like it's somehow just fine to not eat entire food groups which are part of a normal human diet?
13
Great article. I’d also love to see a series on mental health case studies. We have a similar problem in my profession of clinical psychology where many clinicians are not taught to sleuth at a deeper level than individual symptoms or behavior.
13
This is a great story! Our medical/patient care system is set up to only diagnose the obvious and provide minimal time/input into "fixing" patients. I was severely asthmatic with recurring lung infections for 10 years - receiving 10-12 annual doses of prednisone and antibiotics and 10s of thousands of dollars of asthma meds. Finally, a new GP sent me to yet another specialist. The new specialist spent hours discussing my history and ordered dozens of blood and sputum tests. Turned out I had a fungal infection in my lungs - all those years of antibiotics prescribed on the ASSUMPTION of bacterial infections had made me worse, and worse, and worse. One course of anti-fungal medicine and I've been asthma-free and breathing right for five years. Any my insurance bills have plummeted... SO had the patient "care" system been more focused on taking time to make a correct diagnosis at the start of that 10 year period, spending on my care during the 10 years I was improperly diagnosed would have been 10s of thousands of dollars lower than it was (to say nothing of how a correct diagnosis would have improved my quality of life).
10
Scurvy was common not only on ships but in some of the early European explorations of the New World. During Champlain's stay in what is now Canada there was an epidemic that killed man of his men. I find this painfully odd since Jacques Cartier, who had visited the same general area some 80 years earlier, had learned a cure from the native inhabitants, and it was nothing more complicated than a tea made from the needles of the white pine. That kind of tree can grow anywhere, and so the curing medicine was right there in great quantities and requiring next to no preparation. Why Cartier's knowledge never got to Champlain is a mystery.
12
I can only hope that those who religiously embrace the over-hyped celebrity diet du jour and limit a major nutritional component take a lesson from this article.
2
What ever happened to taking vitamins? If you eat right, who needs them.
2
Ha, I am old and as soon as she said she didn't eat oranges, I guessed it was scurvy/ lack of vit. c.
I worked for a boss way back when who had had Polio in the 50's, and every so often he would get some sort of ailment that could not be explained. The unfortunate thing was because Polio had almost died out, the doctors who could treat it were also dying out, and their specialist knowledge went with them.
6
Are doctors not relying on computer-assisted or even computer-led diagnoses? One doctor “writing down a list of possible conditions” seems like such a random and inadequate approach. The “eureka” moment in this story, much too late for the patient, only underscores how much so.
3
What chance would an ordinary GP have to diagnose such a complicated case? I think this woman was cured by seeing a team of doctors at a great hospital like Mass General where there could be multiple disciplines involved. All patients have at times been involved in "medial mysteries" and need to be made aware of getting second or even third opinions. especially women.
2
But she had been to the "great hospital" and was discharged several times before a doctor in training (with an excellent supervisor) at Mass General *finally* made the correct diagnosis.
6
How could someone not be ill with such a poor diet - and was she getting no dental care, either? Gums that bleed for years is also clearly abnormal.
6
Jack London’s fellow Klondike gold miners frequently suffered from scurvy.No citrus foods were available. Interestley, potato peels are rich in ascorbic acid. Those who ate unpeeled potatoes avoided survey.
8
Naranbhai - isn't that a foreign name? Like one of the folks we're planning to slam the iron gate on?? Maybe we'd better rethink our priorities, ya think?
By the way, being an old timer, I diagnosed this before we got to the disease, as soon as they mentioned the citrus. Maybe we'd also better not upset California too much - they might hold their fruit for ransom.
140
Unless it's a Native American name, they're all foreign names. Why do you assume that if the doctor isn't named something Anglo-Saxon he or she is from elsewhere?
3
He’s from South Africa, and was only here on a residency. Nothing to do with immigration.
5
Why should immigration policy be determined by anecdote and snark? People reasonably object when Trump promotes the MS 13 slaying du jour as a reason to build the wall. When it comes to setting immigration policy, I don't care if this doctor was the second coming of Ben Casey.
1
Her medical mysteries inspired me to buy “Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis" and it is wonderful!
27
Thanks, Rico. I’ve been thinking about buying the book.
1
What once was old, is new again!
19
Over 35 years ago a very wise neurologist at my medical school told me that, "History solves the mystery." My father who was also a wise physician frequently said that often the patient would tell you what is wrong with them if only you would shut up and let them.
177
As a child in the UK in the 1950s we were effectively force fed orange juice every day, as little as one teaspoon. It tasted of the metallic cans in which it had been shipped from overseas. Fresh fruit was expensive and seasonal at that time. Incidentally it was provided free to parents. Our mothers knew and we believed them, that it was necessary for our health. Similarly they made us eat an apple every day "an apple a day keeps the doctor away" a homily which I still follow every day. If this patient had been exposed to our mothers' wisdom she would have avoided her pain, anxiety and expense. Thankfully she learned before it was too late.
27
I am surprised that this patient anamnesis was so poor and superficial , especially in a teaching hospital, where it should be at the basis of each diagnosis.
Often the simplest information can be diagnostic .
Modern medicine has left behind the golden rule of a thorough patient’s examination and history, to depend on tests , computers and give extravagant diagnosis .
Iin the USA I detest to have to fill so many papers about my clinical history, when I see that often they are just part of insurance bureaucracy and don’t even get read by the clinicians , too busy darting from one patient to the other .
I have to say that in Europe we have a more human , direct and in depth interaction with our physicians and therefore we have a more trustworthy relation .
“ Bravo “ to the resident who diagnosed scurvy !
84
Welcome to the land where money rules . . .
41
The patient had bruising that not only wasn't healing, but was spreading, and her doctors wanted her to get physical therapy to make walking easier while the bruising healed. Isn't this an obvious contradiction? The bruises weren't healing, yet they wanted her to get PT until the bruises did heal.
An injury that spreads over time can indicate a serious condition. The proper thing to do is keep trying to diagnose it, not pass the patient off to someone else to help the patient cope with the worsening problem.
150
I could tell right away that the paint can wasn’t the cause because the story didn’t say which leg had been injured.
7
nor the paint color, which could have been key.
meanwhile, trying to foist the patient off from curative care by doctors to a cheaper course of physical therapy reveals three things:
her care was dictated by insurance and not by medicine
her docs didn't know what was going on, but thought it would probably resolve itself in time
nutrition is often overlooked by medicine as not sciencey enough
9
Love it! Scurvy! I hope it didn't take a genomic profile test to rule it in. Next week...a good ol case of tetanus or rabies!!!
23
Nah, rabies and tetanus have such violent and distinctive symptoms - like being literally bent over backwards, or foaming at the mouth - that they really can't be misinterpreted. I'm thinking something like porphyria, or symptoms caused by a long-ago injury. It's also nice when, unlike rabies, the condition has a less than 100% mortality rate.
1
Nah they already did porphyria
I find this situation incredible that anyone could be so ignorant. Everyone I know is always popping supplements. Even tho' it useless many pop vitamin c for a cold. Here in the more northern climes many take vitamin d at all ages and what about the ubiquitous one a day type multivite. Clearly she had access to medical care. Many people would say:hey doc what vitamins should I take which would hopefully prompt a brief question if the person was following some resyrictef diet such as vegan.
25
Why are you blaming the patient? The doctors--it's their profession/training--should have been the first to investigate thoroughly every possibility, starting with the most simple explanation, then proceed from there. Not everyone pops a vitamin and, in this case, there is another issue--gastroparesis--which can deplete the absorption of nutrients, no matter what the patient may do or not do.
40
Sounds to me that the patient had no common sense. Who would follow a diet that is completely devoid of fruits and vegetables and not question or ask her doctor if she is missing some key nutrients?
Has school curricula changed that much? In the 1970s, we learned about getting proper nutrition through a balanced diet in public elementary school. Yes, we learned about scurvy, too. Most people understand basic nutrition. I’d also dare to say that most parents would never feed their toddlers such a diet, and would not comply with a school-age or teenager’s request for meals like that.
47
So who put her on this diet initially and didn't give her an effective warning?
2
All those years and years of tedious, often arcane, study. Hundreds of thousands of dollars in tuition and books and whatever else costs money in a medical education. Learning by doing for as many as five grueling years of medical residency.
And it all culminates in a simple mitzvah that means so much.
Sometimes, the world offers wonderful things.
54
Yet after all that education, it took far too much time for the docs to ask a question that should come at the beginning of all diagnoses: “What do you eat?”
6
One would think that they'd ask about diet when the diagnosis isn't immediately apparent, at the very least.
3
A good article as always.
What's missing is what triggered the intern to ask wider questions.
It would be good to know this because first we would appreciate this sleuth more. Importantly, understanding his thought process may make we the readers better patients.
One personal note.
I led a pretty decadent life in New Orleans - some years ago. Not a surprise there.
I lived there for 3 years and used to have my gums bleed constantly. My dentist thought it was a wrong brush. But even dumbing it down to extra soft, same result.
Moved away from New Orleans - less alcohol, more sleep and more importantly, good breakfasts with a glass of orange juice every day.
I have never had that issue again.
Diet is indeed important.
107
It's important not to get fixated on what happened that made some condition apparent as the probable cause of the condition. For example, one day one of my dogs fell into a woodchuck hole while running and viciously twisted her ankle. The ankle didn't get better for weeks and eventually I took her to a vet. When the problem failed to improve under that vet's care, I took her to another with similar non-results. Finally I took her to the University of Pennsylvania Vet Hospital. That vet wasn't all that interested in the woodchuck hole issue. He came in, examined her whole leg -- far away from the point of injury -- and said "I'll have to take some x-rays to confirm, but I believe your dog has bone cancer." Sadly he was right. Everyone else assumed that the pain and the limp were related to the twisted ankle. Rather the fall in the hole made the problem with bone apparent.
132
Had a similar situation which Purdue University's excellent veterinarians immediately caught. Vets are amazing combinations of superb applied science, close physical examination techniques, and superior listening and observation abilities. Human medicine practitioners should pay attention!
48
The stories of scurvy and of peptic ulcer disease have much in common; but most importantly they share the theme that predictive power is a better guide to the truth than common sense.
4
Interesting.. Time to have the computer- robot do a comprehensive medical history. Four eggs a day is a lot of eggs. (I developed asthma and then hives after two egg whites a day for three months.. discovered relationship between hives and egg whites when I ran out of eggs and ate oatmeal.)
How anyone could consider this woman's diet sufficient is beyond me. but the issue is casting a wide net.... which the computer could do. People tire asking the same questions over and over.. but the computer really does not mind.
We need to modernize medicine.
13
A computer would never have seen the small freckles, would never have enquired about her menstrual cycle or her teeth.
5
Gastroparesis is a chronic illness and not an easy one to live with; in fact, it can be quite serious. This is probably why the patient is having trouble eating certain foods, along with having issues of absorption. Why is there no further discussion about the link between gastroparesis and the diagnosis of Vitamin C deficiency? There's probably a big connection. I doubt this patient was purposely avoiding certain foods on purpose.
This is only half the story--I hope the patient is getting further treatment for the gastroparesis and is not being shuffled off again because doctors don't understand how the chronic illness of gastroparesis can affect the body in a major way.
61
Very well written; I'm glad to have discovered the writing of Dr. Sanders.
20
Clues in the Diet. So many health issues have a diet component, especially dehydration. Thanks for a great story.
89
"The Disease of Discovery" Jonathan Lamb
7
That was a great. Still feel that 80% of diagnosis can be reached by a good history and physical.
73
Complex regional Pain Syndrome (CRPS) is a diagnosis (DX) of exclusion and not the first choice as a DX for persistent chronic pain. As a Pain Specialist, I have seen this folly, often sending me on a 'Sherlock Homes' question and answer inquiry to rule out other causes of persistent pain. The internist did an excellent job of holistically accessing the patient and not letting a CRPS DX prejudice his opinion. Diet and lifestyle are a common cause of many medical maladies. Kudos on another excellent and entertaining Diagnosis article.
146
I look forward to Dr. Sanders' column. The resulting cure was so simple yet numerous doctors never thought to ask obvious questions of the patient. Congratulations Dr. Simmons!
71
Steve—this article give the false impression that Vitamin C cures CRPS, and the Dr./author should have clarified this, instead she made it read that it’s a cure-all for CRPS, and that is a blatant falsehood. I have CRPS—for nearly 9 years—I take daily vitamin C tablets, only because the experts in CRPS believe it to prevent spreadin. This is an incurable disease, known to be the most painful disease known—and it is more insidious than just constant pain—it can affect the entire body.
6
Actually, CRPS was a misdiagnosis. The patient had scurvy and the vitamin C cured it.
25
Karen - I can only assume you weren't reading very carefully. The article clearly states that she had scurvy, not CRPS. The author does not give even the smallest impression that CRPS can be cured with vitamin C.
2
I wonder why the patient had suddenly stopped consuming fruits/veggies---I'm assuming she must have eaten them before to not have scurvy for most of her life? Was it that her gastroparesis had only been recently diagnosed? If so, that physician should have also informed her about the vital dietary needs she would have to maintain even if being selective with her food.
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As Hippocrates said, “Let food be thy medicine and medicine be thy food.”
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I thought he said. "First, do no harm." :)
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How about a medical malpractice lawsuit for general stupidity in failure to diagnose a disease that was obvious from the get-go?
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Doctors don't generally see scurvy, You know "When you hear hoofbeats, think horses not zebras." In general you have to work hard to get scurvy, like this woman, or college apartment mate men who lived on pizza and beer and here I'm sure they did not have any vegetables with their pizza.
I assume her diet was didn't include many fruits and vegetables not even potatoes.
Basically scurvy did not show up until long sea voyages, just like pellagra didn't appear until people tried living on unalkaline treated corn.
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That seems like a rather extreme and hostile reaction. Obvious? Scurvy is exceptionally rare.
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You must be an attorney. If we all sued for that reason, there won't be a doctor left in practice.
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