A difficult diagnosis

[Guest guest]

A difficult diagnosis

A short story by S Pisetsky MD PhD, professor of medicine and

immunology at Duke University in Durham NC and editor of Arthritis and

Rheumatism, about the role of trauma in chronic pain.

The characters, as well as the events described, are entirely fictional.

 

" What's the saddest case you ever saw? " I asked my colleague Stan as we sat

in a workroom on Ward 6B. Stan and I were both attending on General Medicine

and were finishing our notes.

" What do you mean 'saddest case'? " Stan asked.

" Something that really got to you, made you want to cry. "

" Why do you ask? "

I guess it was the gloom and grind of attending that had put me in a down

frame of mind.

I looked out the window. The sun glowed orange as it descended toward the

horizon.

Stan swiveled on his chair and spoke. " I've seen every form of cancer and

heart disease, " he said, " but, believe or not, the saddest case I saw was

when I was a medical student on neurology. A nice woman. She had had

encephalitis and, when the attending talked to her, she seemed fine. Then he

asked her questions and it was clear the woman didn't have a clue about

anything that had just happened. She had no short-term memory at all. "

Stan shook his head a few times. " Can you imagine being like that? It really

gave me the creeps. Here was someone who lived completely in the present

because she couldn't remember. She wasn't really a person. She was just a

being floating in time. "

Stan picked up a chart, looked at me and asked, " So, what was your saddest

case? "

I closed my eyes for a second, scanning the past. While I have seen

thousands of patients, Greer probably made me the saddest.

In 1991, had been referred to me by an internist in town. was

twenty-three. A Phi Beta Kappa graduate from the university, she was temping

as a secretary. The antinuclear antibody test was positive and, to the

internist, the case " smelled like lupus. "

When I saw in my office, she was dressed in a gray suit with a string

of pearls. Her brown hair hung loosely and she had no lipstick. She had a

pretty face but looked tired.

I asked to describe her illness. She told me that she had always been

in good health but recently had been hit hard with exhaustion. She said her

fingers tingled and that her whole body was sore. Even temping was a

terrible strain, she said.

My physical exam showed only some joint tenderness. After the exam, I told

that I would give her an NSAID for pain. I did more tests but, except

for the ANA at 1:640, everything was negative.

At the next appointment, I told I suspected that she might have a

disease like lupus. I wanted to be tentative because lupus can masquerade in

all guises and I have been burned more than once in my guesses.

" Can lupus be treated? " asked. " I hate feeling like this. "

" We can try hydroxychloroquine, " I said, as I scheduled a return in two

months.

On the next visit, was no better. She had lost ten pounds and was

having trouble sleeping.

" Sometimes, the pain is excruciating, " said, almost tearful.

I suggested a steroid taper.

The steroids failed, and I worried that I was overlooking something, maybe

MS or AIDS. I did more blood tests, an MRI, and evoked potentials. Again,

everything was negative. had quit her job. I fretted that she was

watching the soaps while I floundered for a diagnosis.

After seeing for almost a year, I decided that lupus was not the

problem, guessing that she was suffering from depression, fibromyalgia, or

something psychiatric.

Like most rheumatologists, I know the literature about trauma and pain. To

help , I thought I needed more history. I was willing to probe.

At the next visit, I performed a quick physical exam before questioning

.

" Think again, " I said to her. " Can you remember anything that could have

triggered these symptoms? "

" Are you trying to tell me my sickness is in my head? " said, the words

clipped.

I shook my head no.

drew her arms close to her body and shivered.

I felt compelled to press. " Are you sure nothing happened before your

illness? An injury, an accident, a traumatic event? "

's face tightened and she began to rub her leg. A twisty movement like

a loop and a slash.

She hesitated a moment and then started to speak as if in a trance. " It was

my senior year in college. The weekend before finals. One of the girls down

the hall said I should take a break from studying and go to a party at the

Theta Omegas.

" As soon as I got there, I knew it was a mistake. It was hot. Music blared.

Then some guy from my Comp Lit seminar came up to me. His name was Bruce.

'Welcome, campus goddess,' Bruce said, putting his hand around my waist.

" Bruce went off and came back with a drink. 'Just some punch,' he said. As

soon as I drank it, I knew something was wrong. I felt dizzy and my head

hurt. It must have been doped. I wanted to leave but my legs felt tired and

heavy.

" 'Take me home, please.' I said to Bruce. 'You don't have to go,' he said.

'There's a place you can lie down upstairs.' He took my arm and led me up

the stairs. " When we got to the room, he pushed me on the bed. I tried to

fight him but I couldn't make my arms move. 'Don't bother screaming,' he

said. 'No one will hear you anyway.' His hands were all over me. He pushed

my legs apart and entered me. I threw up but he didn't stop.

" A few minutes later, he had sex with me again and then he left. I thought

it was over. Then I heard this noise outside the door like howling. Do you

know what a 'train' is, Dr. ? " asked, her eyes shaded in the

yellow-gray light of the room.

My skin felt chilled as I made a vague movement of assent. went on as

the hand movement on her leg became more insistent. " There must have been

ten or twelve of them, screaming, shouting. 'Train!Train!Train!' I must have

passed out. I woke up the next morning in my bed, feeling filthy. I never

told anybody what happened but I can't get those men out of my mind. Every

day, I feel them. I hear them. I smell them. "

looked around the room and ceased the movement on her leg as if a

seizure ended. I struggled for something to say, and then glared at me

and said angrily, " You can't help me, can you? "

then stood up abruptly and ran out the room. I chased after her but

couldn't catch her as she entered the elevator to the clinic entrance.

The next day, I sent a letter about the importance of follow-up and

then called her apartment twice but she never answered.

A few months later, as I was reading the newspaper, I came upon 's

obituary. The cause of death was listed as lupus, but I was convinced

otherwise.

It is almost ten years since I took care of , and I still blame myself

for her death. Whatever was wrong with , I had bungled the case,

failing when I intervened.

" Are you okay? " I heard Stan's voice. The workroom had grown dark. Outside,

yellow-red clouds streaked above the setting sun.

" Just thinking about a patient, " I said to Stan, realizing the awful

symmetry of our saddest cases.

Two women.

One unable to remember. One unable to forget.

S Pisetsky

[Guest guest]

This is so sad, a. Dr. Pisetsky always has something interesting to

say in his short stories.

[ ] A difficult diagnosis

A difficult diagnosis

A short story by S Pisetsky MD PhD, professor of medicine and

immunology at Duke University in Durham NC and editor of Arthritis and

Rheumatism, about the role of trauma in chronic pain.

The characters, as well as the events described, are entirely fictional.

" What's the saddest case you ever saw? " I asked my colleague Stan as we

sat

in a workroom on Ward 6B. Stan and I were both attending on General

Medicine

and were finishing our notes.

" What do you mean 'saddest case'? " Stan asked.

" Something that really got to you, made you want to cry. "

" Why do you ask? "

I guess it was the gloom and grind of attending that had put me in a

down

frame of mind.

I looked out the window. The sun glowed orange as it descended toward

the

horizon.

Stan swiveled on his chair and spoke. " I've seen every form of cancer

and

heart disease, " he said, " but, believe or not, the saddest case I saw

was

when I was a medical student on neurology. A nice woman. She had had

encephalitis and, when the attending talked to her, she seemed fine.

Then he

asked her questions and it was clear the woman didn't have a clue about

anything that had just happened. She had no short-term memory at all. "

Stan shook his head a few times. " Can you imagine being like that? It

really

gave me the creeps. Here was someone who lived completely in the present

because she couldn't remember. She wasn't really a person. She was just

a

being floating in time. "

Stan picked up a chart, looked at me and asked, " So, what was your

saddest

case? "

I closed my eyes for a second, scanning the past. While I have seen

thousands of patients, Greer probably made me the saddest.

In 1991, had been referred to me by an internist in town.

was

twenty-three. A Phi Beta Kappa graduate from the university, she was

temping

as a secretary. The antinuclear antibody test was positive and, to the

internist, the case " smelled like lupus. "

When I saw in my office, she was dressed in a gray suit with a

string

of pearls. Her brown hair hung loosely and she had no lipstick. She had

a

pretty face but looked tired.

I asked to describe her illness. She told me that she had always

been

in good health but recently had been hit hard with exhaustion. She said

her

fingers tingled and that her whole body was sore. Even temping was a

terrible strain, she said.

My physical exam showed only some joint tenderness. After the exam, I

told

that I would give her an NSAID for pain. I did more tests but,

except

for the ANA at 1:640, everything was negative.

At the next appointment, I told I suspected that she might have a

disease like lupus. I wanted to be tentative because lupus can

masquerade in

all guises and I have been burned more than once in my guesses.

" Can lupus be treated? " asked. " I hate feeling like this. "

" We can try hydroxychloroquine, " I said, as I scheduled a return in two

months.

On the next visit, was no better. She had lost ten pounds and was

having trouble sleeping.

" Sometimes, the pain is excruciating, " said, almost tearful.

I suggested a steroid taper.

The steroids failed, and I worried that I was overlooking something,

maybe

MS or AIDS. I did more blood tests, an MRI, and evoked potentials.

Again,

everything was negative. had quit her job. I fretted that she was

watching the soaps while I floundered for a diagnosis.

After seeing for almost a year, I decided that lupus was not the

problem, guessing that she was suffering from depression, fibromyalgia,

or

something psychiatric.

Like most rheumatologists, I know the literature about trauma and pain.

To

help , I thought I needed more history. I was willing to probe.

At the next visit, I performed a quick physical exam before questioning

.

" Think again, " I said to her. " Can you remember anything that could have

triggered these symptoms? "

" Are you trying to tell me my sickness is in my head? " said, the

words

clipped.

I shook my head no.

drew her arms close to her body and shivered.

I felt compelled to press. " Are you sure nothing happened before your

illness? An injury, an accident, a traumatic event? "

's face tightened and she began to rub her leg. A twisty movement

like

a loop and a slash.

She hesitated a moment and then started to speak as if in a trance. " It

was

my senior year in college. The weekend before finals. One of the girls

down

the hall said I should take a break from studying and go to a party at

the

Theta Omegas.

" As soon as I got there, I knew it was a mistake. It was hot. Music

blared.

Then some guy from my Comp Lit seminar came up to me. His name was

Bruce.

'Welcome, campus goddess,' Bruce said, putting his hand around my waist.

" Bruce went off and came back with a drink. 'Just some punch,' he said.

As

soon as I drank it, I knew something was wrong. I felt dizzy and my head

hurt. It must have been doped. I wanted to leave but my legs felt tired

and

heavy.

" 'Take me home, please.' I said to Bruce. 'You don't have to go,' he

said.

'There's a place you can lie down upstairs.' He took my arm and led me

up

the stairs. " When we got to the room, he pushed me on the bed. I tried

to

fight him but I couldn't make my arms move. 'Don't bother screaming,' he

said. 'No one will hear you anyway.' His hands were all over me. He

pushed

my legs apart and entered me. I threw up but he didn't stop.

" A few minutes later, he had sex with me again and then he left. I

thought

it was over. Then I heard this noise outside the door like howling. Do

you

know what a 'train' is, Dr. ? " asked, her eyes shaded in the

yellow-gray light of the room.

My skin felt chilled as I made a vague movement of assent. went on

as

the hand movement on her leg became more insistent. " There must have

been

ten or twelve of them, screaming, shouting. 'Train!Train!Train!' I must

have

passed out. I woke up the next morning in my bed, feeling filthy. I

never

told anybody what happened but I can't get those men out of my mind.

Every

day, I feel them. I hear them. I smell them. "

looked around the room and ceased the movement on her leg as if a

seizure ended. I struggled for something to say, and then glared

at me

and said angrily, " You can't help me, can you? "

then stood up abruptly and ran out the room. I chased after her

but

couldn't catch her as she entered the elevator to the clinic entrance.

The next day, I sent a letter about the importance of follow-up

and

then called her apartment twice but she never answered.

A few months later, as I was reading the newspaper, I came upon 's

obituary. The cause of death was listed as lupus, but I was convinced

otherwise.

It is almost ten years since I took care of , and I still blame

myself

for her death. Whatever was wrong with , I had bungled the case,

failing when I intervened.

" Are you okay? " I heard Stan's voice. The workroom had grown dark.

Outside,

yellow-red clouds streaked above the setting sun.

" Just thinking about a patient, " I said to Stan, realizing the awful

symmetry of our saddest cases.

Two women.

One unable to remember. One unable to forget.

S Pisetsky