To what disease do the symptoms belong,
When dark urine lacks odor so strong?
I made a few points
When I asked about joints
But the truth is I’d rather be wrong.
Synopsis: I’m a family practitioner from Sioux City, Iowa. While my one-year non-compete clause ticks away, I’m having adventures working in new places and visiting friends and relatives. Right now I’m staffing a clinic in Keosauqua in southeast Iowa.
My month in Keosauqua draws to a close tomorrow.
A patient (who gave me permission to write this information) came in today with a puzzling constellation of symptoms for two weeks: fatigue, malaise, chills and sweats, joint pain, morning stiffness, abdominal pain, vomiting and diarrhea. The fingers on the right hand were swollen, visibly larger than those of the left hand, and index and middle fingers had swelling of the knuckle joint close to the hand. I found other abnormal items on the physical exam, my fingers gliding over tiny, painful lymph nodes at the inside of the upper arm, just above the elbow.
On the basis of an impulse whose source I do not know, I asked the patientiof the color of stools had lightened and that of the urine had darkened. They had.
At the end of the visit I said, “You want me to be wrong about everything I’m thinking of because the best diagnosis we can hope for is infectious mononucleosis. That’s the best one. You don’t want rheumatoid arthritis, Lyme disease, or hepatitis, or any of the worst things that I can think of. And I suppose it’s possible that it’s work related. We’ll have to see.”
Not widely known, but the rheumatologists make the diagnosis of hepatitis B more often than the gastroenterologists. Early in the course of the disease, any hepatitis can look like rheumatoid arthritis. Patients can, and do, have severe joint pains without any abnormality of the liver function tests.
Hepatitis B should be prevented by immunizations administered in infancy. However, some parents choose against immunization (which I find foolish) and a very few people will not make antibodies in response to the vaccine.
Hepatitis C can cause similar joint pains, but usually doesn’t. Mostly it causes an overall sensation of fatigue, less often the classic signs of hepatitis, with jaundice and swollen liver.
In medical school, hepatitis came in the classifications of infectious and serum. By the time I finished residency, infectious hepatitis bore the name A and serum hepatitis was called B. The third one, called non-A non-B hepatitis, eventually found the name C. Ten years ago, hepatitis C mostly smoldered along and every once in a while resulted in liver cancer. Five years ago we had a cure rate of 10% and now we have a cure rate better than 50%, and improving.
In the end, the patient’s diagnosis will come from lab work, but by the time the results come back I will have moved on. I will not witness the denouement, the answer to the mystery.
At the end of the afternoon, I introduced the patient to one of the other docs here and made arrangements for follow-up.
The patient lives in a world, a social context with relatives, friends, and a job or two. I will miss out on seeing how the disease affects the person and the world around them.
I will wonder.