Sunday, February 8, 2015

Differential Diagnosis

      When I was in medical school, we used to read a book called Differential Diagnosis by Dr, French.I had a pleasure of meeting the son of this author, who was also a physician.So when we have a patient with any complaint and certain physical findings , we are asked to do the list of possible diagnosis. This is called the differential diagnosis. But what I am talking about is not the same . But this story is related to my recent patient where there was an issue related to common check up that occurs in a physician's office.
      I saw this patient who had COPD ,and was admitted to hospital for shortness of the breath. She was elderly and was oxygen dependent . She had pneumonia. She was quite short of breath and had to be put on large steroids. She took long time to improve. So I had to continue the steroids for longer time . One day the nurse informed me that her blood pressure was elevated. I thought that it may be due to use of steroids which tend to retain salt and water. The elevated blood pressure could be also due to respiratory difficulties . In any case we had to treat it and she was started on medications . In next couple of days her blood pressure seemed to fluctuate from normal to high . I was not sure on the etiology of this fluctuation of the blood pressure. But then the nurse found out an interesting fact which explained the cause of this variation in the blood pressure . The blood pressure in the right arm was high and the one in the left arm was normal. It was interesting to know that along with me there was a cardiologist and a hospital doctor seeing patient , and none of us thought of checking the blood pressure in both extremities at the same time . I ordered the Doppler of the both upper extremity to check on to make sure that there was no blockage of the arteries going to the arms. As I expected there was narrowing of the artery going to the left arm , the right side was OK. So due to this narrowing there was lower blood pressure on the left side.
      There was nothing needed to be done as the treatment as there was no compromise of the circulation.But the main thing for the future was the information that I gave to the patient, that the right arm pressure is the correct one and not the one on left , which was lower.

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