Tuesday, June 27, 2006


It's a strange feeling to have. Wanting to be correct about a diagnosis and trying to balance that with wanting nothing to be wrong with your patient. Often this is simply not a problem. If someone comes in near death from a heart attack or a stroke or from trauma these thoughts don't occur as everything is as black and white as it gets in medicine. Sometimes, though, I am the first person to see the puzzle, and I want to solve it with dash and style.

Case in point. Last night I took care of an individual with very vague complaints... "My back hurts, my foot Hurts, my tummy hurts" etc... The one thing he couldn't fake was his obviously tender and distended abdomen. I felt, after my exam, that his abdominal pain was from urinary retention and sure enough, after passing a foley catheter into his bladder, he diuresed over a liter and a half of urine (and felt much better). While doing this, however, he lost control of his bowels. I say this not for shock, but to add a clue to the diagnosis... He had urinary retention and fecal incontinence. He also had strange and varying pain complaints that could not be put together in a neat diagnosis. Except! Except for something like Multiple Sclerosis (click ''conflicted'' above for more information).

Multiple Sclerosis is rarely diagnosed in the ED and I was sure after further examination, thought, and research that this gentleman had it. He also had, by my exam, weakness in his foot flexor and extensor muscles making him almost a "classic" case.

I did all the preliminary stuff in the ED including a spinal tap and admitted the nice man after a good talk about MS and other possible diagnoses (I had only vague guesses). Today when I found out that his MRI of the brain was NORMAL and that other etiologies were being considered did I feel disappointment? Is that what it was? Maybe. And there's the conflict. I should have been happy but my pride was a bit affected. I wanted to make the ''zebra'' diagnosis and be the smart guy. I think it's a very human feeling but not necessarily a good one.


  1. Final diagnsosi... transverse myelitis.

  2. Still a very close guess on your part. Not your fault you didn't get the exact subspecies of zebra. ; )