It is not a smart doctor who leaps to conclusions. Even though a patient may present with “absolutely classical” signs and symptoms of a particular affliction the wise doctor will still go through the process of taking a medical history, performing a proper examination and requesting appropriate laboratory investigations before making the final diagnosis. It is the final diagnosis that dictates the treatment. Short cuts to diagnosis may well result in inappropriate treatment. Inappropriate treatment may at best be simply ineffectual and at worst may have distinctly adverse consequences for the patient – and doctor. And all is not always as it seems in medicine. Several such examples are described, from my own experience, in the next few pages.
He appeared on the screen as a low priority, back pain. I signed on for a higher priority patient but, in walking past the low priority patient’s bed, I was a little surprised to note that he was a teenage boy. It struck me as odd that a fifteen year old would present with back pain. More commonly it would be back injury. But that was just a passing thought.
A little later I walked past his bed again and observed him to be in very considerable pain and writhing about on the bed. I noted he had not been picked up by any other doctor and there were still higher priority patients waiting. Never-the-less I spoke to the triage nurse and asked her what she knew of him. She told me he had simply told her that he had a sore back and that his observations were normal. Because he appeared very uncomfortable she had allocated him to a bed but had not given him a high priority.
Boys rarely present with back pain and people with back pain lay still – they do not writhe about. I clicked on his name and allocated him to myself. His mother sat alongside the bed looking rather apprehensive and worried. The boy was pale and could not lay still. He had vomited earlier. His urine had been tested and was normal. It became immediately apparent what his problem was. I asked him where the pain was and he indicated his left loin. I then asked if his testicles were painful. He blushed, turned his head away from his mother and nodded. Examination of his testicles confirmed my diagnosis of torsion of the testicle – the left in his case.
I arranged for the surgeon to see him urgently. He did so and took him to theatre a short time later. Afterwards he told me the boy’s left testicle had twisted around on its blood vessels and nerves almost completely cutting off the blood supply. He felt another hour or so would have seen the testicle become gangrenous and necessitate removal. Its colour had returned to normal when it was untwisted indicating it would survive. The usual procedure, when the testicle is salvageable, is to suture it into place to prevent it twisting again. The other testicle is also sutured because the pre-disposing condition is always bilateral. The testicle is normally attached by a ligament to the back of the scrotum. This ligament is missing in those predisposed to torsion.
The boy had been too embarrassed to tell either his mother or the triage nurse about his predicament. He did have pain in the back – referred pain from the testicle – and that had to suffice in his explanation to the ladies. All was not as it seemed to the casual observer. On another day a sixty one year old woman was on the screen as a low priority with vomiting and diarrhoea. It was one of those all-too-rare quiet days and there was no one else waiting to be seen. She did not look very well at all and told me she had started vomiting four days previously. The diarrhoea had consisted of just one, small, watery bowel motion that morning. She had pain constantly, with severe waves passing on top of that. She had not passed any wind.
She was moderately febrile and dehydrated having no saliva in her mouth and the skin on the back of her hand remaining in a drawn up peak when gently pinched. Her abdomen was protuberant and very tender. Gently laying my left middle finger on her abdomen and tapping on it with my right middle finger caused severe, stabbing pain. This very simple action told me she was in deep trouble with much, much more than just the presumed gastro-enteritis that was “going around” - as it always is.
We had great difficulty getting enough blood for even basic tests. The poor lady endured us poking needles into her arms and even a foot and never once complained. There was only one vein we could find that would take a cannulla without collapsing. Fortunately, we were able to get a couple of litres of fluid into her over the next couple of hours while she waited for a CT scan of her abdomen.
I stood alongside the radiologist while he talked me through the series of CT scans. It was obvious, even to me, that she had a small bowel obstruction. What was causing it was not obvious even to the radiologist. However, small bowel obstruction was diagnosis enough to demand immediate transfer to a major hospital which task I got about arranging. (The bureaucracy is taxing!). Just before the ambulance arrived to take her away the radiologist rang me to say that, in fact, she had appendicitis and not only that but the appendix had perforated. In a process that been in evolution over four days the appendix had become inflamed and walled off by inflammatory reactive tissues preventing her developing the classical severe peritonitis. Such things can be very difficult to diagnose even with the modern marvel of CT scans and similar technology.
Appendicitis is very rare in people of 61 years. When it does occur it is often caused by some other pathology such as bowel cancer. I received no feedback from the major hospital so I do not know the outcome with this lady. All was not as it seemed with neither her presentation nor her CT scan.
We all dread dealing with the drug addicts especially the violent ones. But we cannot afford to “cherry pick” our patients off the screen. And so I had to take on a man whose problem was listed as wanting detoxification. This is not uncommon and usually translates into the person wanting us to prescribe morphine or oxycodon or codeine for pain or withdrawal symptoms. We are prohibited by law from so doing. There was nothing to suggest this chap was any different from any other drug addict. He lay on the bed fully clothed but disheveled, gaunt, haggard, and agitated. He told me he had been suffering with chronic back pain for years and had been prescribed increasing quantities and strengths of analgesics until he finished up addicted to morphine. “Here it comes,” I thought. “He is going to ask me for morphine to tide him over for a while.” I was wrong. He wanted to be referred to somewhere to help him get off the stuff.
He told me he had not had any opiates or other analgesics for three days. He said he had been through the hell of three days of withdrawal but had hung in there and refused to give in to his body’s murderous screams for relief from the agonies. He had been in touch with two places that helped people get off drugs. One had told him they would take him in but not for another two days as they were full up. The other said they could not fit him in in the foreseeable future.
We had a long discussion during which I concluded he was genuine and his story was entirely true. Not knowing a great deal about the services available to such people I decided to seek the assistance of the hospital social worker. Saints, those people are. We are tested in the ED, at times to the utmost, but those people are saint like in the way they tolerate daily abuse, even assault and seeing hours or days of effort thrown back into their faces by the ingrates who consider the world owes them a living and much more.
The staff social worker was on leave and her replacement willingly came along to ED. I outlined the problem and she spent two hours or more with this chap. She got his wife to come in and that poor lady had to bring a pre-school child with her because there was no one to look after him. The social worker contacted the organisation that had promised to take him in two days later and confirmed that he had done as he said. The upshot of it all was that we gave him two Valium tablets - one to take that night, and the next, to help him in his attempts to get some sleep. I doubt they helped much but he didn’t want anything else and I didn’t want to prescribe more. He had seen the worst of his cold turkey. If he could just hang in there another 48 hours he would be in the safe hands of professional detoxifiers. His wife was fully supportive of his efforts.
I don’t know the outcome. I sincerely hope he made it and is starting out on a new life which will not be a bed of roses but far better than the painful, terminal illness of opiate addiction. All was not as it seemed with him. I wished him well as he left. He shook my hand and the social worker’s, looked us in the eyes and said, “Thank you both for listening.”
“Rash”, said the problem under the patient’s name on the computer screen. The triage notes told me he had a CT scan, with contrast, three days previously. I, like the patient and the triage nurse, immediately assumed he was suffering an allergic reaction to the contrast medium. That assumption was blown to smithereens with his response to the first question – onset of the rash preceded the CT scan by a week or more. “Yes, it is very itchy and yes, the itch is worse at night.”
I could see no rash on his face or arms and asked him to let me see it. He removed his trousers and shirt to reveal an extensive, bright red rash extending from his navel to his knees, front and back. It consisted of large patches of angry red skin with surrounding areas of small red spots – macules, and some small raised spots – papules. Scratch marks were evident on the skin and on the left thigh there was a patch of skin weeping yellowish, watery fluid. As is my habit, I got my binocular loupe – an instrument similar to binocculars but with a very short focal length usually used to examine the surface of the eyes. I find it invaluable to closely examining the skin especially that with odd rashes. Scrutiny of the peripheral areas of the rash revealed numerous macules and papules. Most informative were the short, serpentine lines within the skin beneath the surface layer or epithelium. They set the diagnosis in concrete – scabies. He was quite surprised when I told him and so was his wife who accompanied him. Close questioning revealed that he had gone to the bush to do a job a few weeks previously and was accommodated in a less than salubrious boarding house. That was probably where he contracted the disease.
Scabies is a very common and highly infectious disease caused by a microscopic, parasitic mite. The female of the species burrows into the skin and lays eggs at the end of a small tunnel. The tunnels are the serpentine lines visible in the skin. The eggs trigger an allergic reaction which causes the extreme itch.
Treatment is relatively easy consisting of the application of a permethrin based lotion from chin to feet, leaving it on overnight and washing off in the morning. This kills the live mites on the skin but not the eggs within the skin which will hatch within 3 to 10 days. Therefore, a repeat application is necessary at ten days, I always recommend a third application after a further five to ten days to ensure all mites are killed. The lotion does not require a prescription and is quite cheap.
I suggested to this patient that he try it and also advised him and his wife to wash the bed clothes in hot water next day and leave them on the line in the sun all day. I also asked him to return if there was no improvement in a couple of days. He returned the very next day and proudly proclaimed that the itch and rash had almost completely resolved already. He displayed the rash and it certainly was vastly improved on the previous day.
A similar patient had presented a couple of months previously. He worked at a remote gold mine in the far north of Western Australia on a fly-in fly-out roster. This necessitated the use of shared accommodation. He presented with an horrendous, bright red, intensely itchy rash which was very obvious on his face and covered his entire skin. He told me he had it for months and had seen several different doctors when he was back from the mine. He had been prescribed various treatments including steroid drugs which relieved his symptoms but they recurred within days of stopping the steroids.
It was difficult to find a patch of skin that was not grossly inflamed but when I did and examined it with my binocular loupe I found the tell tale serpentine lines of scabies. He returned of his own volition two days later to show me how much the rash had improved and tell me the itch had stopped.
Only last month a young woman was sent to us by her GP with a letter stating she needed to be admitted and treated with intravenous antibiotics for severe, extensive cellulitis of her limbs. Her skin was certainly red, hot and swollen but she did not have swollen glands, she was not toxic and not febrile as would be expected with cellulitis as extensive as the rash was. I found the serpentine lines. We commenced her on steroids, to deal with the severity of the inflammation, plus the scabies treatment but also arranged an urgent appointment at the dermatology clinic of a teaching hospital.
Rashes can be very difficult to diagnose on occasions and certainly the rash caused by scabies can mimic many others and is often misdiagnosed. Rashes are not always what they seem.