This story reveals the difficulty we doctors sometimes face in making the right diagnosis.
Here I had a weird presentation of a medical problem. That combined with familial issues delayed the disease determination.
Me: Sir the ER said you have a foot infection and they have started you on IV antibiotics for it. But, if you don't mind - I always like to start from the beginning.
Him: Ok?
Me: So, how did you end up here?
Him: I mean basically, I woke up with a fever and, my leg and ankle were hurting me.
Me: Right leg?
Him: Yup
Me: So nothing was wrong until today?
Him: Nope
Me: OK so what other medical problems do you have? Any diabetes, high blood pressure? Take any medications for anything?!!
Him: Man I am 24, I am good!
Me: OK no medical problems.... Any surgical history?
Him: I had my appendix taken out at like 16, but nothing else.
Me: Ok, appendectomy around 2008. Are your siblings & parents alive and well? Any medical problems??!
Him: I am an only child and I don't know my father.... He left when I was young and my mom is healthy.
Me: Does she know you are admitted? Is she coming here?
Him: Probably..I don't know.
Me: Any alcohol use? Drug use?
Him: umm...[mom walks in the door]
The mom of course has three million questions about everything that is going on. So, I end up rehashing what was said above and eventually get back to the "kid." My last question having been forgotten.
Me: OK so let's go back to the ankle... Is it really bothering you? Does it hurt when you move it?!?
Him: Yea, I can't even step on it..
Me: OK let me check it out...[gently touch the ankle and slightly move it... it is obviously red and swollen]
Him: Dude, I said it hurts... Get your hands off me!
Me: Sorry Sorry! I didn't mean to hurt you! But, I do need to figure out the extent of the problem. Ok fine, can I at least examine the rest of you to make sure there's nothing else wrong.
Him: Man get out of here, I wanna rest...I don't need your hurting anything else!
Me: OK, so you are refusing to let me examine the rest of your body?
Him: No, I am not saying that.....just not right now!
[his mom, tried to chime in here and convince him.....but essentially he told her to "shut up."]
Him: Now, leave me the fuck alone.
Me: Sir, I need to figure out the extent of the problem in your ankle. Considering that even me touching your ankle is causing you pain, I think I need to at least get an x-ray.
Him: Is it gonna hurt?
Me: I can order minimal views - that way it should be quick but yes, it will be painful as they are positioning it for the best view.
Him: Forget it! Just give me the meds and when I am better I will go home.
Me: That isn't gonna work...if you want our care this is what I need to do...or you could lose your foot. I am worried there's an infection in the joint itself.
Him: Seriously?
Me: Yes...
After much back and forth, with the mother also getting involved...he eventually agrees to do a multi-view x-ray of his foot. I order this to be done STAT.
Around 1 hour later - mom had to leave...luckily.
Me: Ok, there's a joint effusion in your ankle and I think you might have septic arthritis.
Him: What the hell are you talking about?
Me: There's a fluid collection in your ankle and I think the fluid is infected. I am gonna need to get an orthopedic surgeon to have the fluid drained so we can culture it to try to figure out which bacteria we are dealing with.
Him: If I don't want to do this?
Me: Basically, if the joint is truly infected and we don't do this you could lose your foot. I explained this earlier.
Him: Come on really? It's actually starting to feel better?
Me: Can i examine it and check if you right about that?
Him: [As soon as I touch it] Ok Ok fine you are right, you are right...go call the surgeon.
Me: Ok good! As soon as I step out of this room I will call orthopedic surgery. Now, I forgot to ask earlier when your mom walked in...do you smoke, drink, do any drugs?
Him: I only drink once in a while that's it.
Me: No cigarettes or marijuana?
Him: No
Me: IV drug use?
Him: No man!
Me: Ok, Ok....How about sexual activity?
Him: Why do you really need to know all of this? It's just a joint infection!
Me: Well some times something as simple as gonorrhea can make it to your joints...so I need to know what we could be dealing with.
Him: Geez...you can get gonorrhea in your joints?!?!
Me: Yup
Him: Damn! Ok well whatever...I have only had sex with one girl and I used a condom...so I doubt I have it.
Me: Ok yea...me too. Ok let me get the orthopedic surgeon.
It had been two days and the joint's been drained. He was slowly getting better on IV antibiotics but, he still hadn't really allowed me to do a full physical exam.
Me: Ok, I have some not so good news.....first off, is you mom coming in? I would like to talk about a few things before she gets here.
Him: You are scaring me...
Me: Yea, I don't mean to do that but it's a serious conversation and I need honest answers.
Him: Ok??
Me: So is she coming in?
Him: Yea in like an hour I think?
Me: Ok let me get this out of the way then. First off, both your blood and joint cultures are showing the same thing. You have staph infection in your blood vessels and in your joint. It's a gram positive cocci that we have luckily been treating already with the antibiotics you are getting.
Him: So it isn't gonorrhea??
Me: No, but this implies something. And I need you to be honest here.....because what we do next changes with your answers.
Him: Ok?
Me: Ok, If your joint started hurting after you got hit or cut and then we found the bacteria in your blood...I would have said that your joint is the primary problem....the spot where the infection started.
Him: Ok......
Me: But you said you woke up with this...right? Meaning, nothing was wrong until the joint randomly started to hurt and you got a fever?
Him: Yea...
Me: Ok so that means to me that your infection started in your blood and then got into your joint.
Him: So how did I get it in my blood?
Me: So yea....so staph usually lives on your skin....ok?
Him: ok?
Me: So, I am gonna ask again: do you have any IV drug use history? Have you ever injected yourself with anything? Could there be any way that you introduced the bacteria off of your skin into your body ?
Him: ............
Me: Look the reality is, no matter what you say I am ordering an echocardiogram. But, if you tell me that you definitely have used IV drugs then I will be calling cardiology and trying to get it done STAT. Because, this blood infection could actually have reached your heart.
Him: You mean.....if I used IV drugs, I could have infected my heart?
Me: Yes
Him: Then how the hell did it end up in ankle?
Me: It's all part of the same blood flow system. There are two possibilities here - one: it started in your joint and ended up in your blood. But if you have never hit or cut your joint then I doubt that's what happened. The second possibility is: you are injecting yourself with needles that, even if they are clean, have introduced your skin bacteria into your blood vessels.
This bacteria then seeded your joint and if it can do that...it could definitely have seeded your heart.
Him: If it is there? Don't I just need antibiotics? The same stuff you are giving me?
Me: Yes but if it's severe enough...some people need surgery?
Him: I might need surgery?
Me: I don't know.....do you do IV drugs?
Him: [after a long pause] Yes like 1-2 times per month....
Me: For how long?
Him: For like the last 6-7 months.
Me: Let me just listen to your heart.
I listen to the heart and hear murmurs that are definitely concerning. But, I am no cardiologist!
Me: ok let me go get the cardiologist and try to get your echo stat...its early in the day he might still be here.
His echo was done. He had obvious tricuspid valve endocarditis. Basically a bacterial infection of one of his heart valves. In addition to this however, he was also found to have weakened heart muscle ie congestive heart failure.
He was transferred to a tertiary medical center for valve replacement surgery that same day.
Last I heard, he was discharged home after his surgery and was supposedly doing better.
Hopefully, he stopped doing IV Drugs.
Until next time!