Listen to your patient
"Listen to your patient, he is telling you the diagnosis."
-- Sir William Osler
Thank you all for patiently reading my first blog post and encouraging me to write further!
I would like to share with you an interesting case that I saw a couple of weeks ago. An 18 year old boy walked into my consultation room with complaints of generalized weakness, gum bleeds, nasal bleeds, multiple petechiae (red spots on the skin) all over the body, loss of appetite, easy bruisability. He had developed the symptoms progressively over a month.
As with any case, within the first few minutes of talking to the patient, I had started forming some hypotheses about the diagnosis and the differential diagnosis.I had to find one theory that will explain all the facts of the case. In most cases, such a systematic approach works very well, but sometimes the differential diagnosis catches you by surprise!
I thought of all the possible differential diagnosis including but not limited to haematological malignancy, platelet disorders, bleeding disorders to name a few. I explained to the patient in the best possible way about the possibilities and gave the list of investigations to be done.
When I saw the patient the next day, he was certainly looking sicker compared to the previous day. His red spots had increased. All the reports - complete blood count, bleeding time, prothrombin time, platelet counts and others - were absolutely normal! Here I was sitting in front of a patient who was looking at me for answers. I started thinking of rarer conditions like functional disorders of platelet, some form of vasculitis etc - all of which would require more investigations and I was nowhere close to treatment. This patient had very limited resources and I had to be absolutely sure before I ordered more tests.
Usually whenever I am not clear about a case I follow the good old method - retake the patient's history. I started asking him about his childhood, occupation etc. I realized that he was a cook and had been working for more than 5 years as one now (so much for child labor laws!). He belonged to a very poor family and was hard up for money.
The diagnosis was staring at me: Scurvy it was!!! Chronic vitamin C deficiency described by none other than Hippocrates himself. I had only read about the disorder but definitely don’t remember seeing one before.
A few centuries ago, Scurvy was a dreaded disease among sailors and pirates. In those days there was no refrigeration in ships. Fruits and vegetables would perish after a few days. So if you are sailing for a long duration, you had to basically survive on salted meat, dried grains (and beer - water would get contaminated at sea). With a lack of vitamin C in their diet, the sailors would fall prey to scurvy. It became one of the limiting factors of sea voyage. Remember all the pirate movies you saw where they had red spots all over the body?
As for my patient, he had an excellent prognosis. I took out my prescription pad and wrote "Orange juice every day" and handed it over to him. I saw him next after a week and he was fit as a fiddle!
The best confirmation of the diagnosis of scurvy is its resolution following Vit.C administration. Now a days, I do look at at all my patients gingiva and teeth as part of general examination not just leave it to the dentist. Who knows when I will see a scurvy case again?
As for you dear reader - please don't forget to have your daily dose of lemon and orange!
-- Sir William Osler
Thank you all for patiently reading my first blog post and encouraging me to write further!
I would like to share with you an interesting case that I saw a couple of weeks ago. An 18 year old boy walked into my consultation room with complaints of generalized weakness, gum bleeds, nasal bleeds, multiple petechiae (red spots on the skin) all over the body, loss of appetite, easy bruisability. He had developed the symptoms progressively over a month.
As with any case, within the first few minutes of talking to the patient, I had started forming some hypotheses about the diagnosis and the differential diagnosis.I had to find one theory that will explain all the facts of the case. In most cases, such a systematic approach works very well, but sometimes the differential diagnosis catches you by surprise!
I thought of all the possible differential diagnosis including but not limited to haematological malignancy, platelet disorders, bleeding disorders to name a few. I explained to the patient in the best possible way about the possibilities and gave the list of investigations to be done.
When I saw the patient the next day, he was certainly looking sicker compared to the previous day. His red spots had increased. All the reports - complete blood count, bleeding time, prothrombin time, platelet counts and others - were absolutely normal! Here I was sitting in front of a patient who was looking at me for answers. I started thinking of rarer conditions like functional disorders of platelet, some form of vasculitis etc - all of which would require more investigations and I was nowhere close to treatment. This patient had very limited resources and I had to be absolutely sure before I ordered more tests.
Usually whenever I am not clear about a case I follow the good old method - retake the patient's history. I started asking him about his childhood, occupation etc. I realized that he was a cook and had been working for more than 5 years as one now (so much for child labor laws!). He belonged to a very poor family and was hard up for money.
The diagnosis was staring at me: Scurvy it was!!! Chronic vitamin C deficiency described by none other than Hippocrates himself. I had only read about the disorder but definitely don’t remember seeing one before.
A few centuries ago, Scurvy was a dreaded disease among sailors and pirates. In those days there was no refrigeration in ships. Fruits and vegetables would perish after a few days. So if you are sailing for a long duration, you had to basically survive on salted meat, dried grains (and beer - water would get contaminated at sea). With a lack of vitamin C in their diet, the sailors would fall prey to scurvy. It became one of the limiting factors of sea voyage. Remember all the pirate movies you saw where they had red spots all over the body?
As for my patient, he had an excellent prognosis. I took out my prescription pad and wrote "Orange juice every day" and handed it over to him. I saw him next after a week and he was fit as a fiddle!
The best confirmation of the diagnosis of scurvy is its resolution following Vit.C administration. Now a days, I do look at at all my patients gingiva and teeth as part of general examination not just leave it to the dentist. Who knows when I will see a scurvy case again?
As for you dear reader - please don't forget to have your daily dose of lemon and orange!