Mystery

Yesterday M was in. She sees me for her back pain, her "sciatica" and her neuropathy. I have done a somewhat nice job of getting her out of a lot of pain. I give her epidurals now almost every three months. I gave her one and it helped for about six months. She also had gotten some Botox injections in the back. Those were very helpful also. But there were some problems that developed. She got pain that didn't seem to fit with everything and I had her go for an MRI, which showed knee problems. I sent her to an Orthopedic doctor, who drained her knee with some help. Then she got severe swelling in the ankle, so he sent her to an arthritis doctor, who tested her for "autoimmune diseases". She had some positive antibodies, but he didn't think she had a real autoimmune problem. She developed bone infarctions (where the bones die from lack of blood flow). She was sent to a blood doctor, who said she has B12 deficiency and is treating that. She has developed severe osteoporosis as well. She was sent to a university expert in bone disease and immune disase, and they didn't really even evaluate her there. They couldn't find all of her records. So basically, none of us really know what's wrong with her. I'll put her on one of the neurology discussion groups, but I doubt that's going to help much. She doesn't really have much of a neurology problem. I'm stopping her Topamax, because that can cause osteoporosis, although not bone infarcts or these other problems. I'm sending her to an endocrinologist next week. She is a mystery.
Sometimes we never really figure it out. This may happen with M. The endocrine person I'm sending her to is extremely smart. He's very thorough and will likely do a systematic careful approach. I need to do that this weekend also. You look up each symptom and generate a long list of possible causes ("differential diagnosis") and see if any of it seems to fit: the larger your list, the higher the chance of getting the answer. the problem is it's still a "chance". Most diagnoses occur quickly by pattern recognition. It's like when we look at someone's face and know who it is. "How did you know who that is?" You can't explain it based on the details of their nose and mouth and skin. In fact, that's almost harder to do.
When we don't know what's wrong it's often just because there's so much that we don't know. there are diseases that exist which we haven't even named and described yet. There are also disease that aren't one disease, they're two or three diseases that are happening at the same time. While we're all trying to find some kind of an answer, we don't have much treatment, so M is in pain and can't really walk very well. She is, on the whole, getting worse. I know that she's frustrated and getting depressed (What else can you expect?) Even if it isn't neurology, you can't just pass it off to another person to figure it out. If they don't get the answer it's still your patient who is suffering. Most of the time when I get a second opinion it's not because I expect that someone else is going to figure out something I missed or got wrong. They almost never do. It's usually so the patient has some reassurance that they went to the "bigshots". Generally, if I can't figure out, others can't either. There's no despair, no giving up. You just keep on going. People don't think that Dori (the blue fish in the movie Finding Nemo) is really that smart. But she is. She says "Just keep swimming; just keep swimming.." That's really a great idea. You just keep swimming.