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Diagnosis: Solving the Most Baffling Medical Mysteries

Diagnosis: Solving the Most Baffling Medical Mysteries

by Lisa Sanders

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A collection of more than fifty hard-to-crack medical quandaries, featuring the best of The New York Times Magazine's popular Diagnosis column—now a Netflix original series

“Lisa Sanders is a paragon of the modern medical detective storyteller.”—Atul Gawande, author of Being Mortal

As a Yale School of Medicine physician, the New York Times bestselling author of Every Patient Tells a Story, and an inspiration and adviser for the hit Fox TV drama House, M.D., Lisa Sanders has seen it all. And yet she is often confounded by the cases she describes in her column: unexpected collections of symptoms that she and other physicians struggle to diagnose. 

A twenty-eight-year-old man, vacationing in the Bahamas for his birthday, tries some barracuda for dinner. Hours later, he collapses on the dance floor with crippling stomach pains. A middle-aged woman returns to her doctor, after visiting two days earlier with a mild rash on the back of her hands. Now the rash has turned purple and has spread across her entire body in whiplike streaks. A young elephant trainer in a traveling circus, once head-butted by a rogue zebra, is suddenly beset with splitting headaches, as if someone were “slamming a door inside his head.”

In each of these cases, the path to diagnosis—and treatment—is winding, sometimes frustratingly unclear. Dr. Sanders shows how making the right diagnosis requires expertise, painstaking procedure, and sometimes a little luck. Intricate, gripping, and full of twists and turns, Diagnosis puts readers in the doctor’s place. It lets them see what doctors see, feel the uncertainty they feel—and experience the thrill when the puzzle is finally solved.

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Product Details

ISBN-13: 9780593136645
Publisher: Crown Publishing Group
Publication date: 08/13/2019
Sold by: Random House
Format: NOOK Book
Pages: 320
Sales rank: 175,712
File size: 2 MB

About the Author

Lisa Sanders, M.D., is an internist on the faculty of the Yale University School of Medicine. She writes the monthly column Diagnosis for The New York Times Magazine, is the author of Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, and served as a technical advisor on Fox TV's House, M.D. She lives in New Haven, Connecticut.

Read an Excerpt

Just a Fever

“I think I’m losing this battle,” the fifty-­seven-­year-­old man told his wife one Saturday night nearly a year ago. While she’d been at the theater—­they’d bought the tickets weeks earlier—­he’d had to crawl up the stairs on his hands and knees to get back to bed. Terrible bone-­shaking chills tore through him, despite the thick layer of blankets. The shivering was followed by sudden blasts of internal heat and drenching sweats that made him kick off the covers, only to have to haul them back up as the cycle repeated itself.

You really need to go back to the ER, his wife told him. The frustration and worry were clear in her voice. He’d already been to the emergency room three times. They’d given him some intravenous fluids and sent him home with the diagnosis of a viral syndrome. He would start to feel better soon, he was told each time. But he hadn’t.

This all began nine days before. That first day he called in sick to his job as a physical therapist. He felt feverish, as though he might have the flu. He would drink plenty of fluids and take it easy and go back to work the next day. But the next day he felt even worse. That’s when the fevers and chills really kicked in. He alternated between acetaminophen and ibuprofen, but the fever never let up. He started sleeping in the guest room because the sweats soaked the sheets and the chills shook the bed, waking his wife.

After four days of this he made his first visit to the Yale New Haven Hospital emergency room. He was already being treated for a different infection. Three weeks earlier he’d developed a red swollen elbow and gone to an urgent care center, where he was started on one antibiotic. He took it for ten days, but his elbow was still killing him. He went back to urgent care, where he was started on a broader-­spectrum drug, which he was nearly done with. Now his elbow was fine. It was the rest of his body that ached.

But his flu swab was negative. So was his chest X-­ray. It was probably just a virus, he was told. The antibiotics he was already taking would kill just about any of the likely bacteria. He should just take it easy till it passed. And come back if he got any worse.

The next day his fever spiked to 106. And so he went back to the ER. There he found a mob scene—crowded with people who, like him, felt like they were sick with the flu. It would be hours before he could be seen, he was told. Discouraged, he went home to bed. A nurse from the ER called the next morning. Could he come back now that the ER was more manageable? He was happy to return.

He may not have the flu, he thought, but he was sure he had something. But the ER doctor couldn’t find it. He didn’t have any chest pain or shortness of breath. No cough, no headache, no rash, no abdominal pain, no urinary symptoms. His heart was beating hard and fast, but otherwise his exam was fine. His white blood-­cell-­count was low—­which was a little strange. White blood cells are expected to increase in the setting of an acute infection. Still, a virus can cause white counts to drop. His platelets—­the tiny blood fragments that form clots—­were also low. That can also be seen in viral infections, but it was less common.

The ER staff sent the abnormal blood results to the patient’s primary care provider and told the patient to follow up with him. He’d been trying get in to see his PCP, but the doctor’s schedule was full. It was the worst flu season in years. When he called again, he was told that the soonest he could be seen was the following week.

The office agreed to order blood tests to look for Lyme and other tick-­borne infections. This was Connecticut, after all. He dragged himself to the lab and waited for his doctor to call with the results. The call never came. In his mind, he fired his doctor. He’d been sick for over a week and they couldn’t see him, couldn’t even call him with the lab results he’d asked for.

He again went to the ER on Sunday, the morning after his wife returned from the theater and insisted he go back. His previous visits and lab abnormalities caught the attention of the physician’s assistant on duty that morning. She ordered a bunch of blood tests—­looking for everything from HIV to mono. She ordered another chest X-­ray and started him on broad-­spectrum antibiotics, as well as doxycycline, an antibiotic for tick-­borne infections. He was given Tylenol for his fever and admitted to the hospital. As he prepared to leave the ER, the flu test came back positive. He was pretty sure he didn’t have it; he’d never heard of a flu lasting this long. But if he could stay in the hospital, where someone could monitor if he got worse, he was happy to take Tamiflu.

The lab called again later that day to say that the test had been read incorrectly; he did not have the flu. But by then other results started to come in. It definitely wasn’t his elbow—­according to the patient, the orthopedic surgeon who saw him in the ER, and an X-­ray. He didn’t have HIV; he didn’t have mono, or Lyme; he didn’t have any of the other respiratory viruses that, along with influenza, had filled up much of the hospital. Yet, after a couple of days, the patient began to feel better. His fever came down. The shaking chills disappeared. His white count and platelets edged up. It was clear he was recovering, but from what? More blood tests were ordered, and an infectious disease specialist consulted.

Gabriel Vilchez, the ID specialist-­in-­training, reviewed the chart and examined the patient. He agreed that it was most likely that the patient had a tick-­borne infection. The hospital had sent off blood to test for all the usual suspects in the Northeast: Lyme, babesiosis, ehrlichiosis, and anaplasmosis. Except for the Lyme test, which was negative, none of the other results had come back yet. Vilchez thought that given the patient’s symptoms—­and his response to the antibiotic—­it would turn out that he had one of them.

And yet, all the results for tick-­borne infections were negative. But there were other tick-­borne diseases, less common in the Northeast but still possible. To Vilchez, the most likely was Rocky Mountain spotted fever (RMSF)—­though it’s much more common in the Smoky Mountains than the Rocky Mountains. The spotted fever part, the rash, was seen in most but not all cases. It’s unusual to find the infection in Connecticut, but not unheard of. Vilchez sent off blood to be tested for RMSF and to retest for the other infections. The following day the patient felt well enough to go home. A couple of days later he got a call. He had Rocky Mountain spotted fever.

The patient, it turned out, had the misfortune of experiencing fever and flu-­like symptoms in the midst of a flu epidemic. Under these circumstances the question quickly becomes not What does he have? but Does he have the flu? Once you get to no, it’s hard to go back to the broader question.

For the patient, recovery has been tough. Though the doxycycline helped with the acute symptoms, it took months before he could resume his usual patient load at work. He just didn’t have the strength or the stamina to get the job done. He feels that the illness brought him as close to dying as he’d ever been. Indeed, RMSF is the most dangerous of all the tick-­borne infections, with a mortality rate as high as 5 percent even with current antibiotics.

One thing he was certain about, however. He needed a new primary care doctor. And he got one.

Table of Contents

Introduction: Solving the Puzzle xi

Part I Burning with Fever

Just a Fever 3

The Flu That Stayed 8

Burning Up at Night 13

Sick at the Wedding 19

Forgotten Triggers 24

A Killer Flu 29

Part II A Pain in My Belly

Excruciating Episodes 37

Was It the Fish? 42

A Bad Stomach Gets Worse 47

A Hockey Stick to the Gut 52

Age of Embarrassment 57

Hurts So Bad 62

Knifed 67

Suddenly Sick, Again 72

Part III My Aching Head

Changing Visions 79

It Started with Sinus Pain 84

The Elephant Trainer Gets a Headache 89

A Sea of Gray 94

Everybody Lies 99

The Worst Ice Cream Headache, Without the Ice Cream 104

An Icepick to the Head 109

Part IV I Can't Breathe

A Deadly Itch 117

Overflowing 122

Muscle-Bound 127

Uphill Battle 132

Brokenhearted 137

Deflated 142

Part V All in Your Head

Honeymoon in Hell 149

A Different Man 154

Unexpectedly Drunk 159

A River of Confusion 164

The Sadness Signs 169

A Terrible Madness 174

High-Pressure Crazy 179

Part VI Out Cold

Passed Out on a Saturday Night 187

Frequent Fainting 192

Cold Case 197

The Deepest Sleep 202

Faint of Heart 207

Pulseless 212

Part VII Strange Rash

Red Scare 219

Near Death at the Hands of Doctors 224

Old-Fashioned Skin 229

Red and Sore All Over 234

A Black Thumb 239

Line Dancing 244

Part VIII So Weak

A Terrifying Silence 251

Total Collapse 257

Fear of Falling 262

An Overwhelming Weakness 267

The Long Haul 272

Wasting Away 277

Missed Signals 282

Acknowledgments 287

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