Dr James Le Fanu: 10 May
There are few more vexatious issues than the overlooked diagnosis thanks to which the reassurance that there ‘is nothing to worry about’ delays the need for urgent treatment. This regrettable situation, and how it might be avoided, is illustrated by a couple of very different cases.
The first concerns a man in his early 30s who noticed a painful swelling in his chest following a bike ride – which he naturally attributed to a pulled muscle. Rest and vigorous rubbing with embrocations did not help, so he took himself off to the family doctor. The swelling, he was told, was a lump of fat known as a lipoma, and he would have to wait patiently until the health service found time in its hectic schedule to chop it out. He sought a second opinion privately, and a biopsy revealed his ‘harmless lump’ to be a nasty tumour on the muscle, known as a sarcoma.
The second delayed diagnosis concerns a woman with a longish history of pain in the right shoulder, which would come on soon after finishing dinner in the evening. Her husband’s massage offered little relief, and she reported how ‘some nights and mornings were very bad, as I felt desperately sick and hot’.
After several months of seeing her family doctor, he sent her for a kidney scan, which showed her kidneys were fine but revealed eight whopping stones in her gallbladder. These were duly removed and the shoulder pain vanished.
The most obvious mitigating factor in both cases is that they were unusual: muscle sarcomas are rare, and it is not common for gallstones to present as a pain in the shoulder.
Still, there has to be some method for distinguishing the rare and the unusual from the tide of everyday complaints. That method has a name: ‘attention to detail’.
Thus, reviewing these two cases in turn, the misdiagnosis of the sarcoma as a harmless fatty lump had to be wrong on two counts. Lipomas are painless and mobile, in contrast to the sarcoma, which is painful and fixed to the underlying muscle.
Next, the woman with a shoulder pain after dinner may seem inexplicable, but there is a limited number of symptoms caused by eating – of which gallstones is certainly one. The penny really should have dropped a lot sooner.
THIS WEEK’S MEDICAL QUERY comes courtesy of a reader from Kent troubled by episodes of marked fluctuations in the intensity of her hearing. One moment everything sounds muffled and she feels cut off from the world, and the next the traffic on the road is ‘booming’. This is particularly marked when she has a heavy cold.
There are several causes of the disturbance of the ‘volume control but the most probable when, as here, it is exacerbated by the symptoms of a cold, is a blockage of the narrow Eustachian tube, resulting in fluid accumulating behind the eardrum.
This can be alleviated by regular steam inhalations and a steroid nasal spray. It also helps to perform the ‘Valsalva’ manoeuvre several times a day – exhaling vigorously with mouth closed and nose compressed. This opens up the Eustachian tube, permitting the fluid to drain away.
drjames@lady.co.uk
The first concerns a man in his early 30s who noticed a painful swelling in his chest following a bike ride – which he naturally attributed to a pulled muscle. Rest and vigorous rubbing with embrocations did not help, so he took himself off to the family doctor. The swelling, he was told, was a lump of fat known as a lipoma, and he would have to wait patiently until the health service found time in its hectic schedule to chop it out. He sought a second opinion privately, and a biopsy revealed his ‘harmless lump’ to be a nasty tumour on the muscle, known as a sarcoma.
The second delayed diagnosis concerns a woman with a longish history of pain in the right shoulder, which would come on soon after finishing dinner in the evening. Her husband’s massage offered little relief, and she reported how ‘some nights and mornings were very bad, as I felt desperately sick and hot’.
After several months of seeing her family doctor, he sent her for a kidney scan, which showed her kidneys were fine but revealed eight whopping stones in her gallbladder. These were duly removed and the shoulder pain vanished.
The most obvious mitigating factor in both cases is that they were unusual: muscle sarcomas are rare, and it is not common for gallstones to present as a pain in the shoulder.
Still, there has to be some method for distinguishing the rare and the unusual from the tide of everyday complaints. That method has a name: ‘attention to detail’.
Next, the woman with a shoulder pain after dinner may seem inexplicable, but there is a limited number of symptoms caused by eating – of which gallstones is certainly one. The penny really should have dropped a lot sooner.
THIS WEEK’S MEDICAL QUERY comes courtesy of a reader from Kent troubled by episodes of marked fluctuations in the intensity of her hearing. One moment everything sounds muffled and she feels cut off from the world, and the next the traffic on the road is ‘booming’. This is particularly marked when she has a heavy cold.
There are several causes of the disturbance of the ‘volume control but the most probable when, as here, it is exacerbated by the symptoms of a cold, is a blockage of the narrow Eustachian tube, resulting in fluid accumulating behind the eardrum.
This can be alleviated by regular steam inhalations and a steroid nasal spray. It also helps to perform the ‘Valsalva’ manoeuvre several times a day – exhaling vigorously with mouth closed and nose compressed. This opens up the Eustachian tube, permitting the fluid to drain away.
drjames@lady.co.uk