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The miraculous marvels of medicine

by
01 March 2017, at 12:00am

Dr DAVID WILLIAMS seeks help for his swollen feet and finds himself on a journey of discovery, where his own attempts at diagnosis meet those of his medical colleagues, with a little natural help

“MORNING!” … “MORNING!” ... “Y’ALL RIGHT?” … “YEAH – YOU?” … “NOT TOO BAD” … “OK, GOOD, SEE YA!” … “YEAH – BYE!” How many times have you had that sort of a conversation, I wonder – even today perhaps? 

If, that is, you can call that a conversation! My dictionary would have it that a conversation is “the exchange of thoughts and feelings by means of speech or sign language” and I guess maybe the batting backwards and forwards of the platitudes above is better than walking straight past someone you know. 

But what would happen if you stopped your interlocutor and replied “Thank you so much for asking, actually I have had this problem for several days and I’d be glad to have someone to share it with…” – what look of horror would cross their face? 

You can at this point turn the page rather than reading on, but in case you fancy sticking with me, it was a few weeks ago when I woke up one Wednesday to find my feet a little swollen. 

Too busy to think much about it, I sped off to work, but by eventide my feet were quite a bit more swollen. 

Strange! By the next morning the puffiness had gone down quite a bit, but lo and behold by the evening the swelling was back. I don’t hold much store in Doctor Google but a quick perusal of PubMed, the online access point to the USA’s National Library of Medicine, suggested that if I wasn’t a pensioner or pregnant, it might be a manifestation of Bechet’s disease, an autoimmune connective tissue disorder, Poncet’s disease associated with articular tuberculosis or maybe even gonococcal synovisitis. Now I can see why people get themselves in a fluster after consulting the internet! 

Three mornings down the line and there was no improvement, so on the way to work at 8am I knocked on the door of my local GP. Try ringing him at that time and you’re unlikely to get through, but they can’t fail to answer a continual rat-a-tat-tat on the door, can they?!

The receptionist, though surprised to see me at the door quite so early, was happy to fit me in at 4.50 that afternoon in a branch surgery in a neighbouring village.

I didn’t actually manage to get there until 5pm, but Simon was happy to see me. We have a great relationship in which, on the very few times I visit him, I bring my suggested differential diagnosis list and he picks which one he thinks is most likely! 

Getting to the bottom of it 

Today was different though. I got a full clinical examination including careful thoracic auscultation and abdominal palpation. This was followed by a comprehensive blood screen – four syringes worth taken away by the courier who had been asked to wait for those samples and a urine test as well.

He hadn’t finished. Next and last was an ECG, which didn’t seem to show any abnormality. I went home thoroughly impressed by this level of attention and it was only later on in the evening I started to wonder whether Simon was overly worried by my medical status. 

A consultation on Monday morning at 8am somewhat relieved me. No, said Simon, he and the nurse had to stay till 6pm and with no other patients to deal with they filled the time with a comprehensive approach to my condition! 

As it was, everything on the blood was normal apart from a raised ESR, the erythrocyte sedimentation rate. We don’t use this rather non-specific marker for inflammation much in veterinary medicine, but it clearly worried Simon somewhat. 

I asked him how many tests we had actually run over the weekend. Admitting he might have been a bit over the top, Simon fessed up (as my teenage sons tell me is the appropriate phrase in modern parlance) that the list that had come back gave him 32 different results. 

Deary me! I had to remind him that the whole point of the Gaussian distribution was that once you had over 20 values, at least one was going to be outside the normal range if you took p to be 0.05. Undeterred, Simon rang the duty consultant at A&E, who suggested a vasculitis screen. 

We had a little discussion, as I felt that given my renal and hepatic parameters were normal, a diagnosis of Wegener’s granulomatosis or sarcoidosis was unlikely. Given the choice of following the advice of a senior consultant or the patient, however, Simon opted for another blood test. 

Two days later I still had this fluid accumulation and now a negative vasculitis screen too. By now I had remembered that my college position at St John’s gives me a private healthcare option, so off I went to the rheumatologist who gave me another full examination and ultrasonography of my ankles. 

All she could do though was add the term “idiopathic” to the diagnosis of dependent oedema, which Simon had already ended up with. Maybe, she said, a vascular ultrasound would be a good idea to rule out a deep venous thrombosis. That did seem a bit farfetched, but along I trundled to the radiology department. 

Fascinatingly, the relevant test was very simple. A Doppler ultrasound of my femoral vein showed that the sound wave of a cough I was asked to provide happily passed from my thorax to the vein in my leg, ruling out a DVT. 

This was all well and good as in a few days we flew off to New York to celebrate our 25th anniversary as I wrote a few issues ago. Compression stockings on the flight out did make me feel a bit of an old age pensioner, but in fact 25,000 to 30,000 steps of walking each day around the city completely resolved the swelling. 

Back at home though, the swelling returned as did the shrugged shoulders of the assembled medics. It was about three months down the line, at about the time I guess I might have got an appointment on the NHS if I were lucky, the swelling miraculously disappeared, never to return. 

We like to think that we have medicine, whether veterinary or human, under our control these days – lots of tests leading to a diagnosis then the newest drugs or the surgeon’s knife to make things better. But perhaps we need to accept that what we are really doing is aiding nature to heal herself. 

And sometimes she is happy to do that on her own when we can’t work out what to do!