The Challenge: Can you solve a medical mystery involving a middle-aged father who suddenly loses strength in his arms and legs?
The Diagnosis column of The New York Times Magazine regularly asks Well readers to take on a difficult case and offer their own solution to a diagnostic riddle. This week, you’ll find a summary of a patient suffering from unusual symptoms as well as links to laboratory reports and images that will provide you with the same information as the emergency room doctors who originally were faced with this medical mystery.
The first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped a number of medical students and doctors.
The Presenting Problem:
A 52-year-old man experiences aches and pains followed by sudden weakness in his limbs, making it impossible for him to stand.
The Patient’s Story:
In the middle of the night, the 52-year-old man called out to his son in the next bedroom. When the sleepy 21-year-old appeared in his doorway, he found his father sprawled on the floor, unhurt but unable to get himself up off the floor, where he’d fallen while trying to get to the bathroom.
“Can you help me get back on the bed?” the father asked calmly when his son appeared. The young man nodded awkwardly; he was mentally challenged and rarely spoke. The father talked his son through the necessary steps to pull him on to the bed, then called a friend to come over right away to stay with his severely disabled son. Once he was certain his son would not be alone, he dialed 911.
The Emergency Room Exam:
Once the man reached the emergency room, he told the doctor that he had been fine until a couple of days earlier when his legs started to hurt. The pain was most severe in the morning but, day or night, he felt a relentless ache in his hips and knees whenever he walked. Similar pain had come and gone before, he said, but starting two days ago the pain became unbearable. His shoulders hurt as well.
Earlier in the week he had been visiting another son in the hospital, and the pain had prompted him to walk into the emergency room. But after waiting to see a doctor for a few hours, he had to leave to pick his son up from day care.
He returned the following day and finally saw a doctor, who told him the pain was probably just a touch of arthritis and gave him a prescription for an anti-inflammatory drug.
But he never had a chance to fill the prescription. That night he had fallen and couldn’t get up, which is how he found himself back in the emergency room talking to yet another doctor. Now the aching joint pain was gone, but his legs and arms felt weak, numb and strangely heavy.
The physician ordered a series of standard blood tests, an electrocardiogram to check the heart and a computed tomography scan of the head to make sure he hadn’t suffered a stroke.
The Test Results:
Both the CT scan and the E.K.G. studies were normal. You can click on the images to take a closer look.
The blood tests revealed a number of abnormalities.
The patient’s glucose level was high; he had a strong family history of diabetes. The results also showed that the patient’s white blood cell and platelet counts were low.
A thyroid study revealed that the patient had too much thyroid hormone.
The blood work also revealed why the patient was so weak. His potassium, a blood chemical central to muscle function, was extremely low. So were his magnesium and phosphorus levels.
The E.R. doctor did not piece together a diagnosis from the test results, but since the patient’s low potassium level was life threatening, he admitted the patient to the intensive care unit and called the I.C.U. resident.
All of the notes from the patient’s time in the E.R. as well as the lab test results can be found here. (Click on the box on the lower left to enlarge.)
The I.C.U. Resident’s Exam
Dr. Kathleen Samuels was having a busy night. A resident in her second year of training, she had already admitted a half dozen patients to the intensive care unit of the Waterbury Hospital in Connecticut when she got the call about the middle-aged man with the sudden weakness. She finished up her last admission and hurried over to see him.
Dr. Samuels listened as the patient explained his medical history. The joints in his hips, knees and shoulders were rubbery and lacking strength. Otherwise he felt O.K., not sick at all.
He had no other medical problems, and hadn’t been to a doctor in years. He took no medications, didn’t smoke or drink and had never used drugs.
Something like this had happened once a couple of years before. He’d felt weak and had trouble walking, but it had gone away after a day or so and he hadn’t given it another thought, until now.
He was a regular visitor to the hospital because his oldest son, who also had disabilities, had been admitted to the hospital with intractable vomiting a couple of weeks earlier. The two sons had been abandoned by their mother a decade earlier, and since then the father had shaped his entire life around caring for them.
Dr. Samuels examined the patient. He had no fever but his heart was beating rapidly – just under 100 beats per minute – and his blood pressure was a little high. His hands shook, but the patient said he’d had that tremor for years.
At rest he seemed quite comfortable, but any time he tried to move his arms or legs, particularly on the left side, his face contorted in pain. He could barely lift his arms and legs off the bed. And he couldn’t lift them at all if the doctor applied any pressure to the limb. A muscular man like this should be able to overcome this kind of resistance easily. He couldn’t. Although both sides were weak, his left side seemed worse than the right. Was he really this weak, or was pain part of what limited his movement? Dr. Samuels wasn’t sure, and the patient couldn’t tell her.
Dr. Samuels and her intern helped the patient to his feet. He was unsteady but able to take a couple of wobbly steps holding his legs wide apart, like a baby taking his first steps. The two doctors helped the patient back onto the bed.
Dr. Samuels tried to piece together the meaning of the lab results. The patient had a family history of diabetes. Was the high sugar simply a response to stress, or an indicator of diabetes? If he did have diabetes, was there any way that could account for the electrolyte abnormalities?
The excess thyroid hormone could explain the patient’s tremor, but it wouldn’t cause his weakness. Was it playing any role in the electrolyte abnormalities?
The blood work showed that the patient’s white blood cells and platelets were low, and he was anemic as well, causing Dr. Samuels to question whether there might be something wrong with his bone marrow.
The patient’s low potassium was the most urgent problem. Certainly replacing the electrolyte would restore the patient’s strength, but Dr. Samuels wanted to know why it was so low to begin with. His phosphorus and magnesium were dangerously low as well. Normally these blood chemicals are tightly regulated by the body, but in this middlle-aged man, they were far out of whack.
Diarrhea can cause low potassium, as can many medications. But this patient didn’t have any gastrointestinal symptoms and took no medicines at all. Kidney problems are an important cause of low potassium, and though the lab work suggested the patient’s kidneys seemed to be working fine, the doctor would need to look for other renal diseases that could cause this kind of electrolyte imbalance.
Resident Report
It was nearly dawn by the time Dr. Samuels had written her notes and put in the orders to admit this patient to the I.C.U. Although she had a plan on how to treat the man’s chemical imbalances, why he had suddenly developed these life-threatening deficits remained a mystery. For now, all she could do was to replace what he had lost.
At 7:30 that morning she went to Resident Report, a daily event in physician training where much of the teaching on diagnostic thinking takes place. Six mornings a week, residents and teaching physicians gather in a conference room to think through a case of some interesting patient admitted to the hospital. This morning Dr. Samuels was to present this man’s case as a mystery for her colleagues to try to solve.
The Challenge:
Can you figure out what is going on with this devoted father who experienced a sudden onset of weakness?
Rules and Regulations: Post your diagnosis and questions for Dr. Sanders in the Comments section below. The correct answer will appear tomorrow on the Well blog. The winner will be contacted. Select reader comments may also appear in a coming issue of The New York Times Magazine.
