DIFFERENTIAL DIAGNOSIS

Is It Or Isn't It? What The Heck Is It?

Tom woke me up moaning in pain.  His foot was throbbing, swollen and slightly red.

I was pretty sure right away that I knew what it was.  About 6 months ago the exact same thing had happened to me. I waited several days before going to the doctor and when I did, they x-rayed for a stress fracture but found nothing; took blood to test for uric acid level to diagnose gout and found it was not elevated, but decided to treat it as though it was anyway.  They gave me medicine, put me in a boot so I would stay off it and predicted that the intense pain would immediately diminish. It did and I was soon well.

There were differences.  Tom's hurt just below the last joint in his middle toes; mine had been in the last joint in my little toe; gout usually occurs in the big toe.  His hurt more when he walked on it; mine hurt all the time.  But then men are tougher than women, aren't they?  And of course he walked on it all the time, against my strong advice, while I rested mine and elevated it.  He believed that, whatever it was, exercise--at least moderate exercise--would be beneficial, as would loud complaining.

He limped around for more than several days (so like a man) and listened to the law office entertain guesses -- an insect bite causing Lyme disease was one ominous diagnosis. Stress fracture and gout got equal votes. Someone supposed that a scratch from one of our cats, called cat scratch fever, could  be responsible. My consistent prediction, shored up by my google research,  was always gout and I urged him to go to the doctor.

At the same time he was having some intestinal problems, which he had used otc medicine to deal with, diarrhea, to be specific. Suddenly it was the day before our trip to our annual family fourth of July week Edisto beach trip and he realized he couldn't head off to such an isolated place, with only one doctor--if she was still in practice--without checking things out. We spent the day going from doctor to doctor; first for the intestinal problem, then for the gout.  The intestinal problem was taken care of quickly enough, but the foot problem required a long wait and then we had to be seen by a new doctor.

First an x-ray to eliminate the possibility of a stress fracture-same thing they had done with mine-then a blood test which revealed no elevated uric acid, then the diagnosis of gout-just like mine!  (I was
right, wasn't I, Tom!)  He got a shot, a prescription for a round of 

 steroids and an admonition to stay off it as much as possible while in Edisto, with the promise that the medicine would work its magic and he would soon feel better.

 
He did not! 

 Every night he went to bed with his foot swollen and throbbing, swearing he would stay off it the next day.  

Every day he went crabbing, swam with the grandkids, rode out on the boat for hours (though at

least he didn't go tubing), danced on the porch during our talent shows and danceathons.

Jeff recommended some folk remedies which he had read about, on-line of course. Cherries were the ticket.  Tom is a great believer in the old adage "in for a penny, in for a pound"   and more is better, so he ate cherries, and ate cherries and ate cherries till every dish and trash can in the house was filled with cherry pits and he was doing midnight runs further and further off island to grocery stores, as the nearby ones sold out of cherries.  Unfortunately Jeff also suggested celery. Soon the bunches of celery crowded out the eggs and milk and other essentials in the refrigerator and the continuous celery crunch assaulted our ears. Tom's foot got no better.

Several weeks after we returned home,  we went to an orthopedist, who, pursuing the idea that it might not be gout, decided to do further testing.

Doctors really don't know.  I used to think they did.  They talk to you about your symptoms; they perform various tests; then they know--they diagnose; they treat,  based on their diagnosis and then you get well.  How could I have been so naive?
What they do is,  they take an educated guess.  Then if that isn't it, they eliminate that diagnosis and go to the next possibility, then the next, till they hit the right one--if they are lucky.  It is called differential diagnosis.  They are good at it and usually get it right the first time--or the second.

They got Tom's right the second time.  Dr. Burnworth ordered an MRI which revealed what the xray had not--a stress fracture. Now the treatment of this many times is a boot--that big, heavy, removable, Velcro wraparound with straps that has a rocker bottom.  It stabilizes your foot while it heals, yet you can walk on it--carefully. Tom was unwilling to wear such a thing--too unwieldy, too time consuming to put on each morning.  The doctor agreed to let him wear his Birkenstocks,  because they have a stiff sole which gives much support to the foot.  We left armed with pain medicine, some topical pain reliever to apply to his foot and an admonition to stay off it.

He did not!


Tom really tried.  We had many meetings to attend though--The Hispanic Leadership Conference, the Christian Action Council Racial  Healing Workgroup, the Carolina Peace Resource Center, Food Not Bombs, Homeless Helping Homeless. Our turn to work at Transitions for supper, the HHH car wash, a worship service that we were the worship leader for were all on the calendar.  Our garden was in full tending mode.  And of course there is the law firm.  No time to rest and put his foot up--even under doctor's orders.  He did make some concessions.  When we went to the grocery store, he used a wheel chair--and loved it. He didn't use the electric one, but the manual one, which he propelled down the aisles and across the parking lot with great abandon.  After his knee on the other side started hurting because of the way he had to walk to favor the injured foot, he did use a cane. Sometimes, when he wasn't doing anything else, he did elevate it.  He did let me do some things in the garden that he usually does--but sometimes I would catch him out there.

His foot continued to hurt, to swell, to be red.  Our next adventure was with his friend, Tim,  of Pedorthic Orthotics who fits orthopedic corrective devices, which Tom wears in his shoe because of an old football injury. Tim persuaded him to wear a short, simplified boot. Desperate to do something, he agreed to try it. He has been in it since.  Tim said he would notice a difference right away.

He did not!


It got worse.  In addition to continued pain, the swelling took on a whole new shape--which we agreed was quite odd.  The next emergency visit to Dr. Burnworth on  August 29th was quite a revelation, to him and to us.  Another x-ray showed a new fracture in Tom's foot, next to the original one--this time large enough that it did not take an MRI to reveal it! 

Now what?  Tom is really trying to take it easy. He is iceing the foot every hour, staying off it more and worrying.  He is scheduled for a bone density test on Monday.  The doctor didn't call it Osteoporosis, but I believe that will be his differential diagnosis. 

He mentioned Boniva.

  You know--Sally Fields--on television.  Pharmaceutical advertizing. 

We'll see.