Stepping Over the Curb

A 64-year-old married executive was admitted to the hospital through the emergency room with the presumed diagnosis of cellutis and osteomyelitis of his left fifth toe. While clinicians presumed that the presentation was related to infection, there were a few things that didn’t add up –  he had a slightly elevated white blood cell count but all markers of inflammation were normal and he had no fevers. X-rays and MRIs showed some bony erosions, but the biopsies and cultures remained negative.

Because of some diagnostic uncertainty that was eating away at me, I curbsided rheumatology. In hearing the details that I assumed were pertinent to share with them, and after reviewing the available radiographs, they agreed that the presentation could very well represent an infection.

After discharge, when symptoms persisted and the patient was referred to rheumatology, another diagnosis was established rather quickly. In looking at the toe, a psoriatic patch on the patient’s elbow, and learning of his history of Achilles tendonitis (which was not communicated to the rheumatologist during the curbside), the rheumatologist immediately diagnosed psoriatic arthritis.

Curbsiding rheumatology and sharing the facts as they appeared to me (with my inherent biases) may have been the wrong course of action. If instead, I had consulted the rheumatology team in the hospital and let them draw their own conclusions, the diagnosis may have been made earlier, sparing the patient additional time with worry and suffering; this may have allowed us to begin definitive treatment earlier.

This episode taught me an important lesson:  while a good history taken by a competent physician is critical to elicit all the necessary facts, how one puts these facts together is also a critical piece of the puzzle and is dependent on background, knowledge, and experience. I will keep that in mind the next time I curbside a specialist.