Every Patient Tells a Story (11 page)

The findings were pretty impressive. A careful physical exam changed the patient’s diagnosis and treatment in twenty-six out of one hundred cases—one in four patients. And in almost half of these cases, had Reilly not discovered the correct diagnosis on exam, it would not have been found by “reasonable testing”—that is, testing that would have been ordered if these physical findings had not been discovered. In those cases, the correct diagnosis would have only become apparent when the disease progressed and the patient worsened.

These were important discoveries. In one striking case, a patient who was admitted to the hospital for difficulty breathing was thought to have a tumor in his chest, picked up on his admission X-ray. He had been scheduled for a biopsy of the mass. When Reilly examined the patient, he found a loud heart murmur. Based on the location and timing of the abnormal sound, he realized the noise was caused by an obstruction in one of the valves of the heart. The blockage was causing the vessels leading up to the valve to enlarge with the excess blood—the way traffic backs up when construction or an accident narrows a busy highway. The “mass” seen in the chest X-ray was actually the blood-engorged vessels. The biopsy was canceled and the patient was referred for the surgical repair of his valve.

Another patient had a fever, but no source of infection had been found. He was being treated with intravenous antibiotics. Reilly noticed that one of the patient’s toes was discolored in a way that suggested the toe had been cut off from the body’s blood supply and had become infected. Surgery was consulted and the toe was amputated. The fever disappeared along with the toe.

This handful of studies suggests that a thorough physical examination can play a critical role in making a timely diagnosis—a role that cannot be duplicated by even the sophisticated tests we now have available.

One of the ironies of our technology-laden age is that many of the time-and labor-saving devices that have crept into our daily lives often save neither. Most computer desktops include a virtual notepad. Is it any better than the actual notepad kept in your pocket? A calculator can be essential for performing complex functions, but does it save time when all you really need to do is add, subtract, or multiply a few numbers?

In the same way, medical testing is one way to come up with a diagnosis, but sometimes—and if Brendan Reilly is right, up to 25 percent of the time—you can get the right answer by simply examining the patient.

This is not to say that a physical exam can substitute for testing. With the tests we now have at our disposal, we can diagnose diseases that in another era, not so long ago, could be identified only at autopsy. But the physical examination can direct the doctor’s thinking and narrow the choice of tests to those most likely to provide useful answers—saving time, saving money, and sometimes even saving lives.

The Language the Body Speaks

The experience of being ill can be like waking up in a foreign country. Life, as you formerly knew it, is put on hold while you travel through this other world as unknown as it is unexpected. When I see patients in the hospital or in my office who are suddenly, surprisingly ill, what they really want to know is “What is wrong with me?” They want a road map that will help them manage their new surroundings. The ability to give this unnerving and unfamiliar place a name, to know it—on some level—restores a measure of control, independent of whether that diagnosis comes attached to a cure. Because, even today, a diagnosis is frequently all a good doctor has to offer.

That was certainly the case with Gayle Delacroix, a fifty-eight-year-old retired soccer coach and gym teacher who came to the small community hospital in Connecticut I work in with a puzzling illness.

It was in the late summer of 2003 and Gayle and her longtime partner,
Kathy James, were on their way home from a two-month camping trek across the country—driving, biking, and hiking from northern Connecticut as far west as the mountains of Colorado. They’d planned to end up in their own beds by the weekend. It had been a great summer, until one night, when Gayle was awakened by an excruciating pain across her lower back. The pain was sharp. Stabbing. Unbearable.

Gayle woke her partner: “Something’s wrong with me,” she told her. In the flickering glare of the flashlight Kathy saw that Gayle’s face was slick with sweat, tense with pain. Though the summer night was cool in the mountains, her skin was hot and Kathy didn’t need a thermometer to know that her partner had a fever.

Her head hurt, Gayle told her. And she felt hot and cold at the same time. But worst of all, she had this intense pain across the lowest part of her back. It had that precise yet elusive quality of an ice cream headache. Sharp needles of electricity flashed down the back of her legs every now and then, but the back pain was persistent, gnawing. Her teeth chattered as she spoke. Her body shook with wracking chills.

Kathy realized that Gayle needed a doctor. She dressed and quickly stuffed her sleeping bag into a sack. Helping Gayle out of the tent and onto the stump they’d used that evening for a table, she packed up their gear and hurried down the trail to the car. Then she returned to help her partner down the rough track.

They drove an hour through the back roads of West Virginia to Maryland. Another hour to an exit marked with the white H promising a hospital ahead. The ER doctor was practically a kid. Tall, wiry, with stylish glasses and a rumpled scrub shirt over blue jeans, he looked like he’d just crawled out of bed. He helped Gayle sit up and quickly examined her back.

He offered a diagnosis and some reassurance.

“I don’t think the fever and the back pain are related,” he told them. “I think the back and leg pain is sciatica. And the fever—who knows? Some virus, probably.” He gave Gayle some ibuprofen and a muscle relaxer for her back. When Kathy—angered at the breezy exam and unconvinced by his diagnosis—brought up the possibility of Lyme disease (“We’ve been camping,
for God’s sake”), he dutifully wrote out a prescription for doxycycline, the antibiotic of choice for this disease.

Kathy was worried—she was a physical therapist. She had seen lots of sciatica but none this bad. And this fever? Hard to believe they weren’t related. Gayle, on the other hand, was relieved by the reassuring diagnoses. She had never been sick and wasn’t ready to start now. After leaving the hospital they drove until dawn, then checked into a roadside motel and caught up on the sleep they’d missed. They slept soundly—Gayle with the help of the ibuprofen, the muscle relaxer, and, at Kathy’s insistence, the doxycycline. When they awoke it was late afternoon.

Gayle sat up. She felt a little better, though her legs were strangely heavy as she swung them to the floor. When she tried to stand, they buckled beneath her and she fell back, helpless, onto the bed.

“My legs aren’t working, Kathy. I can’t walk.” Gayle’s voice was high-pitched and terrified. “I can’t walk,” she repeated.

Kathy’s heart began to race. She knew it. There really was something wrong. They weren’t far from Baltimore—maybe there? No, Gayle insisted. She wanted to go home.

They were at least five or six hours from the small Connecticut city they lived in. Kathy drove as fast as she could directly to their local hospital. “It was the longest five hours of my life,” she told me later.

“Stay here,” she instructed her partner and disappeared into the emergency room. She returned a few minutes later with a couple of EMTs—emergency medical technicians—and a wheelchair. The three of them helped the now crippled woman out of the car and hurried her into the ER.

Dr. Parvin Zawahir, a first-year resident, was the doctor on call that night. She quickly reviewed the thin chart that documented the patient’s time in the ER. A fever of 101. Weakness. The blood work already done didn’t show much—the white blood cell count wasn’t elevated. Chemistry was normal. Liver—normal.

She found the patient’s curtained-off cubicle, introduced herself, and began the familiar process of taking a history. It had started five days ago, Gayle told her. She had a stomachache and some diarrhea. She figured it was
a touch of food poisoning and didn’t think much of it. Two days later she’d developed a rash on her neck. It didn’t itch or hurt and she hadn’t even noticed it until Kathy pointed it out. She thought at first it might have been a spot rubbed raw by the strap of her bicycling helmet, but the next day it had spread to her legs and stomach. Then yesterday, she’d felt tired after shooting a few baskets—not her normal stamina. But she hadn’t actually felt sick until that pain woke her up almost twenty-four hours ago.

Any bites? Zawahir asked. Gayle nodded. Lots. She’d gotten plenty of mosquito bites. Didn’t recall any tick bites. She hadn’t been around anyone who was sick. No pets. She didn’t smoke—never had. She didn’t drink or use drugs.

The young doctor looked closely at the rash. It was faint but covered much of her body. It was made up of dozens of small, slightly raised, slightly red bumps.

Her back looked normal enough and had no tenderness. The rest of the exam was unremarkable until she got to the patient’s legs. Gayle was able to wiggle her toes and move her feet forward and backward. But she couldn’t lift her legs—at least not the left one. Zawahir sat down at the desk and started on her admission note. How was she to put all this together? Was this a problem of the muscles? That was the only part of the exam that was abnormal. Or was it the nerves that empowered the muscles? The kind of pain the patient described—with the electric charges down her leg—certainly sounded a lot like the sciatica the Maryland ER doctor had thought it was. But Zawahir couldn’t believe that the fever and pain were separate problems. That didn’t make sense. They started at the same time. No, they had to be linked.

Infection seemed most likely. Being outdoors for all that time, she was a perfect candidate for Lyme disease. On the other hand, the patient had been in Colorado and West Virginia and a dozen points between—was there Lyme disease in these places? What about Rocky Mountain spotted fever? That was also carried by ticks and characterized by a fever and a rash. And it could be deadly.

Could it be a mosquito-borne illness? In Connecticut, every summer
there was a big scare for Eastern equine encephalitis. Though she didn’t know how many cases of this disease there were in a year, she’d read that it was frequently fatal. What other viruses could do this? Could this be West Nile virus? Herpes encephalitis? She wasn’t sure. She’d never seen any of these illnesses.

She would need to do a spinal tap to see if the lab could find any bacteria or evidence of infection in the fluid. And she would send off for more blood tests as well. An MRI would show if there was an infection in or near the spinal cord. She would start her on high-dose antibiotics—one that would cover both Lyme and Rocky Mountain spotted fever. And she’d like to get an infectious disease consult. Maybe a specialist could help her figure this case out.

Although she’d taken care of sicker patients, the intern was worried about the near paralysis of the patient’s legs. If you catch a neurological injury early enough you can sometimes reverse the damage. If not, this youthful, active woman could be crippled for life.

After rounds the next morning, Zawahir sought out Dr. Majid Sadigh, an infectious disease expert in the hospital and one of the smartest doctors she knew. Every doctor knows someone like this—the guy you go to when you’re stumped. Or worried. Or scared. In every hospital or community of physicians, there is always that one doctor whose clinical acumen and breadth of knowledge seem far greater than anyone else’s. There is no list of such names or awards given for this honor. It’s simply word of mouth among physicians. In central Connecticut, Sadigh was one of those doctors.

Majid Sadigh had trained in infectious disease in his homeland of Iran. In 1979, not long after Sadigh had completed his training, Mohammed Reza Pahlavi, the U.S.-supported monarch (known here as the Shah of Iran), was overthrown in a religious revolution and Sadigh and his family were forced to flee. He ended up in Waterbury, Connecticut. In order to practice medicine in this country, all foreign-trained physicians have to complete a residency here, regardless of their previous experience. The program Sadigh was accepted into was small but widely respected for the high quality of its teaching. Sadigh’s skills were so impressive that by the end of the first year
of what is normally a three-year program, he was made chief resident. The following year, he joined the faculty at Yale Medical School and has been there ever since.

From the first days of his residency, Sadigh realized that he had a skill almost unknown in this country: he understood the techniques and the value of the physical examination. In Iran even simple tests are often unavailable. In this setting a physician must rely on the patient’s story and physical exam to make a diagnosis. “The body is there, filled with so much, so much to tell you. But if you do not speak the language, you will be deaf to its secrets. My job,” he told me, “is to teach our residents this important language.”

Zawahir briefly laid out the case for Sadigh, then took him to the patient. The young doctor watched with interest as Sadigh spoke to Gayle and Kathy. He sat down next to the bed and began to question the two women about what had happened. Then he carefully examined Gayle, paying special attention to the affected left leg. He elevated both heels, cupping them in his palms a couple of inches above the sheets.

“Lift your right leg,” he instructed. As she struggled to raise the weakened right leg, the paralyzed left leg sank a bit, but not low enough to touch the sheets.

“Now lift the left.” Gayle bit her lip as she strained to elevate the partially paralyzed leg. As she worked, the right heel sank down to the bed as she recruited the strength in her hips to raise the leg. The left leg never budged. Replacing her legs on the bed, he tested the strength in her lower legs.

“Push against my hand with your feet like you are stepping on the gas.” The right foot flexed forward; the left barely moved. He touched her gently on both legs.