I have been in medicine for many years and I have realized that many times all that one has to do is to listen to a patient's story . Now I can also say that many times the diagnosis is simple or straight forward and the talk may not help e.g. straight forward asthma. But when there is a diagnostic dilemma we need more history , so we can order tests that can clinch the diagnosis rather than ordering tests that may take us on wrong path and delay in knowing what a patient has. That brings me to my story for today.
I had known this patient from my evaluation in office . He was 73 years old and was quite obese. He seemed to have sleep apnea, but did not want sleep apnea. He had also smoked and had COPD - the disease that one gets due to smoking. He had be started on oxygen and his activity level was very limited and he had not done any diet. He went to ER one day. He felt weak. The ER doctor saw him and did some routine tests and was admitted .The hospital doctor saw him and at the request of patient. I happen to see the doctor and he told me that he has admitted my patient and has called me for the consult ,but 'he looked ok and should be ready to ho home in 1-2 days . ' I went to see the patient. He had his family with him . I asked him as to what was the reason that he came to ER he was not short of breath but felt weak. I told him to tell me what exactly happened . So he told me that he was sleeping on floor - rather unusual thing in this country. But then when he tried to get up he could not and he had to crawl to his bedroom. He barely pulled himself in the bed and then when he had to go to kitchen he had to crawl again and so then his family called 911 and he was brought to ER. I am a lung specialist .But I told him to raise his arms and he could barely do it and to me it looked like shoulder problem may be rotator cuff injury , but he told me that it was worse than his usual shoulder problem. I asked him to raise the legs and he could not. His oxygen saturation was ok and his lungs were clear . His chest X- ray was fine and routine blood tests were OK. But I was concerned about his weakness and so I ordered CT scan of cervical - neck spine and also Lumbar spine and consulted a neurologist.
The scans were done and they showed as expected lots of arthritis. So then the neurologist ordered a MRI of spine and concluded that he had a SPINAL STROKE . He suggested physical therapy. He felt that there was issue with spine and that will need physical therapy and some time . He signed off the case. Next day he looked weak and little short of breath and then I send him to a monitor bed as I was concerned about worsened neurological status . The spinal stroke is where the function bellow certain level of the spinal cord there is muscle weakness or paralysis. I talked to him and his family. I told them about my fear that he may have paralysis of breathing muscles and then may need respirator. He told me that he would never go on respirator and wanted to sign papers right there . His family also felt the same thing and so we made him DNR . I called the neurologist and talked to his associate as he was not in the office and told him my fear of what is called ASCENDING POLYNEUROPATHY. In this condition the weakness ASCENDS from lower level to higher level So when respiratory muscles get involved then one cannot breath. He came in and agreed and started treatment. Patient did not want any artificial support to sustain life and so in next 24 hours he passed away.
The story that patient had was suggesting that something was happening and this was not the usual 'weakness ' that happens in many older patient who are obese and who have other lung and heart problem like this patient had. Just allowing patient to tell what exactly happened helps and then diagnosis becomes clear.