On Monday I challenged Well readers to figure out a medical mystery involving a middle-aged man with persistent hiccups.
More than 275 readers submitted their guesses. Many readers recognized that the man’s confusion, low blood pressure and involuntary movements were side effects of Thorazine, the drug given to treat the patient’s hiccups. And, almost as many made the link between the patient’s surgery earlier in the week and his hiccups. But only three readers were able to correctly identify how the two events were related.
The correct diagnosis is …pulmonary embolus.
The first two correct answers came within seconds of each other. And so, although we usually assign only one winner, in this case there will be two.
I asked one of the winners, Dr. Mark Lowell, an emergency room physician in Ann Arbor, Mich., how he figured out the case, and he laughed.
“I think everything is a P.E.” he told me, noting that he’d done research on pulmonary embolism. “What’s going to fool you the most? What’s the worst thing this could be in a healthy guy with something funny going on in his chest?”
Our second winner is Dr. Michael Benjamin, a physician specializing in hematology and oncology in Los Angeles. “The challenge of course with P.E. is thinking about it, so kudos to the P.A. for figuring it out. He probably saved the patient’s life.”
The Diagnosis:
Pulmonary embolus occurs when a clot that formed somewhere in the body breaks free, travels in the circulation and eventually lodges in the lung. It can be a serious problem, even life threatening. And it can be very tough to diagnose.
The condition is not uncommon; each year, more than 100,000 cases of pulmonary embolus occur in the United States. The symptoms are not very specific: patients often feel short of breath, their heart may race, they may have chest pain or cough up blood. Or they may not feel much at all. Up to a third of patients may not have any of the symptoms usually associated with these clots.
How the Diagnosis Was Made:
When the patient became lightheaded after the second dose of Thorazine, Steve Ferrante, the physician assistant handling the case, knew that a drop in blood pressure is a common side effect of this medication. And the uncontrollable movements of the patient’s arms and legs were consistent with a condition known as akathisia, a usually transient disorder that also is a common side effect of Thorazine and other antipsychotic medicines.
However, that sudden drop in blood pressure could also suggest other, more serious diseases as well, and Mr. Ferrante started to worry that maybe he was missing something.
Then Mr. Ferrante remembered hearing about two other patients coming to the same emergency room within the past couple of years. Both patients had come in with hiccups and both were diagnosed with a pulmonary embolus.
Mr. Ferrante’s patient had undergone a hernia repair operation just a few days earlier. Post-surgical patients are at increased risk for developing clots, most commonly in the legs. This patient didn’t have the typical symptoms and had none of the swelling or redness that would suggest the presence of a clot in his leg. But a clot could form in the abdomen or pelvis, and moving around, as this patient had, could have caused the clot to break up and be carried away by the circulating blood, ending up in the lungs.
Other Cases of Hiccups:
In the 1970s a psychologist named Arthur Elstein conducted a series of experiments pitting doctors who were widely considered “expert diagnosticians” against physicians who were considered to be just good “regular doctors.” Each were asked to solve a series of tough diagnostic cases. The assumption was that the experts would solve more cases than the regular doctors. What they found instead was that the doctors most likely to diagnose a tough case were those who had already encountered a similar case — either through their own experience or through hearing about someone else’s experience.
Mr. Ferrante had learned about other patients with persistent hiccups from Dr. Getaw Hassen, an attending physician in the Metropolitan Hospital emergency room on Manhattan’s Upper East Side. The first patient was a 54-year-old man with progressive shortness of breath and swelling in the legs. Doctors had admitted him to the hospital for further work-up and treatment, but the patient had left after a couple of days against medical advice. He returned a week later, complaining about four days of unrelenting hiccups. The doctors found a massive, life-threatening pulmonary embolus.
The second case arrived in the emergency room a few months later. This was a 40-year-old woman who came to the same emergency room complaining of several days of flank pain and hiccups. A CT scan showed that the hiccuping woman, who two weeks earlier had undergone a hysterectomy, had a large pulmonary embolus.
With these two cases in mind, Mr. Ferrante added a CT scan of the lung to the lab studies he had ordered. (You can see the CT scan to the right.) The radiologist spotted the occlusion and notified Dr. Hassan. The patient was admitted to the hospital and treated with anticoagulants. The current recommendation is that patients with a first pulmonary embolus continue to take anticoagulants for at least three months.
Why would a clot in the lungs cause a patient to hiccup? It’s hard to know for certain, but it seems likely that a part of the lung that was injured by the loss of blood flow must have been next to the diaphragm and caused some irritation that led to hiccups.
The Patient’s Story:
It’s been a couple of months now, and the patient will soon be able to stop taking the blood thinner. It is a difficult medicine to manage, and he’s had to go in to see his doctor for a blood test and possible dose change every week since he started taking it. The patient tells me he has seen more doctors this summer than he has in all his previous 46 years. He can’t wait until he’s done. Indeed, it’s hard for him to believe he’s had to take this medicine just because of a case of hiccups. That, he tells me, was nothing compared to how awful he felt when he got that second dose of Thorazine. That sense of being out of it and having his body take on a mind of its own really scared him. And despite what his doctors tell him, he’s not completely convinced that the drug — and not the hiccups — isn’t somehow to blame for everything else.
Facing the threat of thunderstorms, the search continued Tuesday for a severely autistic 8-year-old boy who ran away from his elementary school into the San Bernardino National Forest, authorities said.