The Medical Mystery: What tests need to be ordered to help reach a diagnosis for a young woman with chronic pain that has lasted for a decade?
The Diagnosis column of The New York Times Magazine regularly asks Well readers to sift through the details of a difficult medical case and solve a diagnostic riddle. This month’s puzzle is a two-part challenge that will require you to really think like a doctor. That’s because, just like the real doctor involved in the case, you’ll need to decide what tests should be ordered based on this patient’s medical history.
Post your test request, and if the test was actually ordered, I’ll post the results in the comments section throughout the day. Follow the test results, and once you have figured out the diagnosis, post your answer. The first person with the right diagnosis gets a copy of my book “Every Patient Tells a Story,” and the satisfaction of solving a tough, tough case.
Let’s get started.
The Presenting Problem:
“Will you see my sister?” the young woman asked. Dr. David Podell’s office had told her the doctor wasn’t taking new patients, but she wondered if he would see her sister just once. “She’s so sick and has been to so many doctors, and no one knows what she has.” The woman had heard Dr. Podell described as a kinder and gentler version of Dr. House, the cantankerous television doctor who specializes in medical mysteries. Dr. Podell was a rheumatologist who specialized in odd diseases and who might, she hoped, be able to untangle the complex case presented by her older sister’s mysterious illness.
Dr. Podell listened to the woman, a colleague of a colleague, as she briefly laid out the story of her sister, now 32, who over the past 10 years had become completely disabled by strange pains and odd episodes of weakness that no one could explain. She handed Dr. Podell a letter her sister had written to him. It painted such a picture of suffering that he knew he would have to say yes.
“I am very desperate for help and I am struggling every day all day without relief,” the sister wrote.
“I have heard you are the best and if there is help out there you are the one” who will make it happen, she continued. “Please give me back my future.”
(You can read the entire letter below; click on the box in the lower left to expand in a new window.)
Dr. Podell wasn’t sure he could help, but he agreed to see her. However, she lived in Ohio, and before she traveled all the way to Middlebury, Conn., to see him, he would need to get a copy of her medical records with all the testing she’d had done, and he would need to talk with her by phone.
The Patient’s Story:
Dr. Podell called his patient-to-be that Saturday afternoon. Her voice was soft and high-pitched, making her sound younger than her 32 years. She told him that she couldn’t really remember when it all started but that her whole life had seemed one of near-constant pain. Now she was at a breaking point. It started to become unbearable when she was pregnant with her now 7-year-old daughter. She’d had to spend most of that pregnancy in bed because of terrible back pain. Her pelvis had separated prematurely, she’d been told. And her pain had slowly been getting worse ever since.
Her parents, who lived nearby, had been wonderfully supportive over the past several years. She didn’t realize how much she’d come to depend on them until they went to Germany on vacation — their first in a decade. Suddenly, without their help, she realized how limited she was and how much they had done to make her life possible. On the days when she couldn’t get out of bed, they would help her get her young daughter to and from school and help her with the shopping. With them out of town, she felt overwhelmed and helpless. She’d turned to her sister, who lived in Connecticut and could provide her with at least the emotional support she needed, and called her every day, sometimes several times a day. That’s when her sister had begun to look for a doctor who could figure out what was going on with her, and that’s how she found Dr. Podell.
Dr. Podell asked about her pain. She told him it was everywhere, really. All over her body. In her joints, in her muscles, even her skin. She had severe fatigue and yet she couldn’t sleep. She’d be up for days and then crash. She had migraine headaches frequently. She had irritable bowel syndrome. She was severely depressed. She’d been given a diagnosis of fibromyalgia. She was anemic. She had endometriosis.
Recently she’d had these episodes in which she would lose all her strength on one side of her body. The first time it happened it was just her left arm. She went to the emergency room and had a CT scan of her head done because the E.R. doctor was worried that she’d had a stroke; so was she. But the scan was normal. Her strength came back the next day. No one figured out why that happened.
She told Dr. Podell that she felt like her body was on fire all the time. She was weak and tired and her mind felt foggy, but nobody could tell her why. Her voice broke on the phone, and Dr. Podell could hear her sobbing quietly.
The Doctor’s Exam:
Dr. Podell was worried. As a rheumatologist, he specialized in diseases of the tissues that hold the body together — bones, muscles, tendons — and saw a lot of people who had pain all over their body. But he wasn’t sure what this patient had. What if he wasn’t able to figure it out? “She’d put all her eggs in my basket,” he told me. “And I didn’t want to drop it.”
He also didn’t want her to arrive at his office only to find he had nothing to offer her. So, in addition to having her doctor send him results of all the tests and procedures she’d had so far, he wanted her to get a few others. Actually, he wanted to get a lot of other tests before she flew in for a physical exam.
Maybe it wasn’t good medicine, he said, but he wanted to cast a wide net to look for a cause of her symptoms even before he saw her. He was determined not to miss this diagnosis. “I went for the zebras because, frankly, after all the doctors she’s seen, I was pretty sure all the horses had already been looked at,” he said.
One of the tests that Dr. Podell ordered contained an essential clue in the diagnosis of this patient.
The Challenge:
If you could order only one test for this patient with intermittent weakness and chronic pain all over, what test would you order, and why?
Post your responses below. If the patient had that test done, either by Dr. Podell or by the doctors she saw before him, I will post the test result. I will be posting new information in response to requests every hour or so after 6 a.m.
Follow the test results, and once you think you’ve figured out the diagnosis, post your guess.
Tomorrow, I will post the correct diagnosis and tell you what happened when doctor and patient finally met.
Rules and Regulations: Post your test request and diagnosis 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.
