Agraphia Medical Tragicomedy

21Oct/08Off

Three Stories

Back pain is one of the most ubiquitous complaints seen in the ER. The vast majority are back sprains or drug seekers, but occasionally something more sinister lurks underneath. Let us consider three cases I saw today; by the end of the day, one patient will go home on pain medications, one will be admitted to the hospital for a life-threatening blood clot, and one will be diagnosed with cancer for the first time.

The first was a 23 year old male who torqued his back while lifting a heavy crate at the shipping dock. For 2 days he's had severe, wrenching back pain. On examination he has visible spasm of his paraspinous muscles, which are incredibly tender to the touch. His left leg is weak, but that's because it hurts his back to use it. A quick prescription for muscle relaxants and some painkillers with physical therapy, and he'll be good as new.

The next was a 38 year old known narcotics-seeking, chronic back pain patient who hops from ER to ER, shopping for pain pills. He looked frightened when I examined him, as if he realized he cried wolf too many times and this time nobody would listen. Something was off, though; unlike most drug seekers, he didn't jump and howl in exaggerated pain the moment I pressed on his back. In fact, his back wasn't painful at all, no matter how hard I pushed, and the pain was too high up to be "low back pain".

Looking through his records, I found a clotting disorder that was diagnosed years ago. Because of his drug seeking behavior, his original doctor stopped seeing him and he was never treated. A CT scan of his lungs (ordered amidst jeering from nurses who knew him all too well) revealed a pulmonary embolus; a massive clot that dislodged from his legs and blocked off one of the arteries in his lungs, potentially fatal if not caught early. He was admitted to the hospital for observation while being anticoagulated.

The last was an incredibly pleasant, polite 58 year old with no history of back pain. He thought he sprained his back three days ago, because it had been hurting nonstop. In fact, even while lying down at night he couldn't seem to get comfortable. Concerned, I asked a few more pointed questions; he had lost 5 pounds in the past 2 weeks, and was so tired he hadn't even been able to make it to the corner store to support his two-pack-a-day smoking habit.

I ordered a simple series of lab tests on him, and was horrified to find my suspicions confirmed - a serum protein gap, acute renal failure, and anemia - almost pathognomonic for multiple myeloma, a type of bone cancer. We referred him to oncology after having a tearful conversation about his future.

This is the reason for all of the school, all the training. In medicine we deal with the 10% of the time that things are not what they seem. The true art of medicine is learning to distinguish between the mundane and the aberrant.

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  1. Nice post… just one pedantic quibble: multiple myeloma is not a type of bone cancer – it’s a haematological malignancy of plasma cells. Oesteoclastic activity leads to lytic bone lesions, which is where the bony disease comes from.

  2. True! Good point, I should have been more specific.

  3. Good stories! Keep them coming.

  4. This is a great read for my situation, Should declare that you will be possibly the best blog writers I JUST ever before found. Cheers for the purpose of post this information.


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