Moving on to the posterior chest, I heard a faint wheeze in the right mid-lung field, but not in the left. After placing one finger on the lower posterior chest wall, I percussed the lower lung fields—an old-fashioned way of assessing whether fluid is present in the chest. The tapping had a reassuring normal hollow ring. A flat tone would have suggested a collection of fluid surrounding the lung.
The abdomen was normal. Even the liver, chronically infected with hepatitis C, was nontender and of normal size and consistency. The left knee was crisscrossed with scars and held a cup of fluid. Leon winced slightly when I flexed and extended the joint. “Orthopedics says I can get a new knee anytime I’m ready. The inner part is bone against bone.” He reached down and massaged the damaged knee. “If you’ve got time, I could use a cortisone shot. Seems to hold me for four or five months.”
“Sure,” I replied. “Let me have Joanne come in and set up for that and I’ll be back in a few minutes.” The medical student and I walked back to my office. “Well?” I asked the resident.
Follow the Clues
“Did you get a chance to review the lab?”
“I did. Most of it was abnormal.”
“And? What do you think? You heard the story? Want to give me your top four in your differential diagnoses?”
The resident cleared her throat. She ploughed ahead. “Okay. I think he has more than one diagnosis. The knee is osteoarthritis. It’s a mechanically damaged joint, and the cortisone shot should help, at least for now.”
“Okay, I’ll give you that. Osteoarthritis is a safe bet. And that probably explains his back pain as well, right? But he has a whole lot going on besides osteoarthritis. Go on.”
“Well, the fingers are swollen and stiff, and he has a rheumatoid factor in his blood. I’ve heard that sometimes RA is systemic; people can have fevers with it, as well as fatigue.”
“True,” I replied. “Maybe he has RA, but it’s more or less restricted to his right hand, and RA is usually symmetric. Think about his other symptoms: muscle aches, weight loss, sweats. Any other thoughts?
No one goes to the grave with an undiagnosed disease without a wallop of steroids.
“Smoker. Chronic cough. He could have lung cancer. If he hasn’t had a chest X-ray [CXR] lately, that would be on my checklist.”
