Misdiagnosis and responsibility - case study

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Hi All,

 

Some folks have asked me to post the case study of my patient who died recently.

Here it is. There weren't a large number of visits, but there is a great deal

of information.

 

 

 

Visit 1 August 16, 2006

 

Chief Complaint - pneumonia and pain in lower right side

 

History - first symptoms July 17th. Had pain in back and chest for 2 days and

pain with breathing and dry cough which lasted for 2 weeks. Sore throat started

in the middle of the first week, after the chest pains. Sore throat was

intermittent, worse with coughing. Fever started 1 week after onset, to 105

degrees. Also temporal headache on onset which worsened with start of

antibiotics on July 24th. Antibiotics didn’t help. Spent 1 day in the

emergency room, was prescribed albuterol inhaler which he has not used. Took

echinacea and goldenseal tablets for 2 weeks, and soup with raw garlic and

onions. Was diagnosed with pneumonia 2 weeks ago and a mass was found in his

left lung, biopsied 8-11-08, results pending. Tests for Legionnaire’s and

Valley Fever are negative.

 

Pain in chest and back with breathing persist. Cough is still dry and

productive only 5% of the time, with sticky, blood-streaked greenish-yellow

mucus. Coughing fits last 5-10 minutes, make his throat sore, and cause

vomiting. Hard to take a deep breath without pain and coughing. Nose is

occasionally stuffy, but mostly clear. Has had drenching daytime sweats and

night sweats the whole time. Profound fatigue.

 

Mentally foggy and tired, stressed about work and relationship. Has needed to

strongly curtail activity level and work (works as a mechanic), because activity

causes labored breathing and heavy sweating. Sleep is reduced and poor due to

coughing and inability to get comfortable. Irritable. Wakes on and off all

night. Dreaming of bleeding to death!

 

Despite sweating, does not feel hot. Currently running low-grade fevers on and

off. He still has body aches with sensitive joints.

 

All of the skin on the bottoms of his feet flaked off in thick layers, in the

last 2 weeks.

 

Resting chest/lung pain is 2-3/10, increasing to 7-8/10 with deep breaths.

Joint pain is 3-4/10. Pain in right side is 5-6/10.

 

Ears are not stuffy, but he reports ringing and distortion in his sound

perception.

 

Heart and ekg are fine.

 

Appetite has been very look since getting sick, with a loss of 20 lbs. Stomach

is irritated from coughing.

 

Not thirsty, drinking only 2 glasses of water daily, but mouth and throat feel

dry.

 

Had diarrhea 1st week of illness, with normal stools afterwards. No unusual

urination symptoms.

 

Complexion: ruddy overall with red forehead, nose, chin, cheeks, and chest,

with an underlying paleness beneath. Voice: soft, breathless, dry, coughing.

Dusky fingernails.

 

Tongue: pale, narrow, indented tip, slightly tender sides, and red papillae on

tip. Thick, moist, greasy, creamy yellow coat.

 

Pulse: rapid at 106 bpm. medium depth, regular rhythm. Left: weak, small,

thin, tight overall with slippery middle and distal positions. Right: slightly

weak and slightly small, tense overall with superficial distal position, soggy

middle, and fine proximal.

 

Diagnosis: Phlegm heat toxin in lungs as sequelae to heat in the qi level..

Treatment: cup back and chest. Strengthen lung, earth and kidney, clear heat,

moisten dryness.

 

UB-13, UN-43, DU-4, UB-23, UB-52, LI-11, LI-4, LU-7, KI-6, ST-36, SP-6, LU-8,

LU-5, ST-40, LU-1, LU-2, Ren-17, Ren-12, Ren-6. #36 needle, retain only 5

minutes.

 

Recommendations: increase water intake, increase intake of apples and pears,

stews, barley, soups; reduce soy, dairy and citrus.

 

Notes: Head clearer after treatment and energy increased.

 

Visit 2 August 21, 2008

 

No biopsy results yet. Right ribside pain is almost gone, cough is almost gone.

Breathing well - able to take deep breaths and more talkative. Less chest pain

with deep breaths. Rare shortness of breath unless active. Night sweats

continue, but less frequent and less intense. More focused, but still mentally

foggy. Still has drawn appearance. Appetite back to normal, regained 3 lbs.

More active, but tires easily. Joint aches gone.

 

Tongue - pale with orangey sides, slight scallops, thin moist white coat but

thick, yellow and greasy in rear. Fewer red papillae. Fingernails less dusky.

 

Pulse - 92 bpm, less rapid. Right - slippery, rapid, forceful; proximally

deficient. Left - thin, slippery middle position, fine and weak distally.

 

Same diagnosis, repeat treatment.

 

Third Visit August 30, 2006

 

Worked 8 hours today, usually has 12-14 hour workday. Feels tired. Coughs more

when tired. Face has good color, eyes are a little brighter. Cough is totally

dry and has been for weeks. No shortness of breath but gets fatigued. No more

night sweats but still not sleeping well. Daytime sweating has also stopped.

Lung biopsy negative for cancer, valley fever and legionnaire’s disease. Chest

x-ray scheduled for Friday. No more weight gain. Pain in right side is gone.

 

Tongue: Pink, slightly pale, slightly bare sides, slightly red tip. Thick

cheesy light yellow coat in rear.

Pulse: 94 bpm. Right - superficial, slippery, hollow. Left - thin, soggy,

slightly tight.

 

Diagnosis - overall qi, yin and blood deficiency as sequelae of qi level heat.

 

Treatment - nourish yin, qi, and blood; open ren and chong, clear heat, downbear

lung qi.

 

LU-7 & KI-6, SP-4 & PC-6, Ren-18, Ren-17, KI-25, KI-24, KI-23, Ren-12, Ren-6,

Ren-4, LI-11, LU-8, LI-4, ST-36, SP-6, ST-40, KI-3, KI-2, LIV-3. #38 needle,

retained 15 minutes.

 

Fourth Visit September 6, 2006

 

“Doing great”. Working full days, 10-12 hours. Coughs toward end of day and

also in drafts, cough is still dry. Saw MD yesterday - all blood tests are

negative (unsure what was tested), wants to do test for Wegener’s

granulomatosis. Knees and elbows achy from jet skiing. No noticeable

breathing impairment. Cough is deep, but rare.

 

Tongue - pink with tender red sides and tip; cheesy medium-thickness yellow

coat.

 

Pulse - 86 bpm. Right - slippery. Left - hollow

 

Diagnosis - yin, qi and blood deficiency as sequelae of qi level heat.

 

Treatment: strengthen lung, kidney, spleen - UB-13, DU-14, UB-20, UB-21, UB-23,

DU-4, UB-52, KI-3. #38 needle, retain 15 minutes.

 

Fifth Visit September 12, 2006

 

Sick Saturday - coughing more, achy, fatigue from catching a chill in the rain.

Not much cough today, but lungs feel “tickly”. Eyes deeply red today. Gets

tired 1-2 pm, takes a nap, and goes back to work.

 

Tongue - pink, red tender edges and tip. Thick, greasy and cheesy light yellow

coat.

 

Pulse: 88 bpm. Right - slippery. Left - thin & tight. Deficient middle

position, soggy distally.

 

Diagnosis - wei qi xu; sequelae of wind cold invasion transforming to internal

heat

 

Treatment - strengthen lung, spleen, kidney. LU-1, LU-3, Ren-17, Ren-18,

Ren-12, LI-10, LU-7, LU-8, SJ-4, ST-26, SP-6, KI-7, KI-3, LIV-3. #38 needle,

retained 10 minutes.

 

Herbs - Zhi Sou San, Wise Judge (Kan’s blend of Sha Shen Mai Dong Yin and Sheng

Mai San), Jade Windscreen for 4 days. Then take only Wise Judge and Prosperous

Farmer (Kan’s Xiang Sha Liu Jun Zi Tang) while on 3 week vacation in Italy.

 

Sixth Visit 3 months later - December 17, 2006

 

Eyes deeply bloodshot, occasionally sore. Injured back lifting 2 weeks ago -

sore on right side, can’t lie on right side, taking hydrocodone. Occasional

sharp pain in left biceps when lying on it. Improves with ice, but he hates

that it makes him cold. Occasional chills after hot baths and at work during

the day. Energy and stamina are good. High stress. No urine problems, no

diarrhea.

 

Tongue - pink with slightly red edges and tip. Dry, slightly yellow coat,

medium thickness.

 

Pulse - 92 bpm. Right - medium depth, fast, slippery. Left - thin and tight.

 

Diagnosis - overuse injury with local qi and blood stagnation. Kidney qi/yang

deficiency.

 

Treatment - all on right side: GB-30, huanzhong, Gb-34, Gb-41, local ah-shi

right hip and inguinal area. #30 needles on back; #36 needles on front. Retain

35 minutes.

 

Herbs - Kan’s Dynamic Warrior (Jin Gui Shen Qi Wan) and Meridian Circulation (Du

Huo Ji Sheng Tang), for his history of achy joints in cold weather.

 

Seventh Visit, 10 months later - September 6, 2007

 

Difficulty breathing with mild exertion, like walking to the car. Worse

outdoors and with hot weather; better in air conditioning and swamp cooler.

Hardly any cough. Sinuses congested all year - lots of light green phlegm and

stuffiness, currently scanty. Whole body achy for 3-4 weeks, more intense

outdoors. No fever or chills. “constant fatigue”. Sleeping well. Worked all

through the night 3 nights in a row, 3 weeks ago, without sleep. Appetite low,

worse when feeling hot. Severe stomach issues last 2 months - occasional

nausea, constant slight heartburn, both getting progressively worse. MD

prescribed nexium for daily vomiting mornings, evenings, and 5-10 minutes after

eating. Minor upset stomach since starting nexium. Has 2 meals most days (10

am and late afternoon/evening) with occasional snacks. Eating a lot of hot

spicy pickles, pasta, and other spicy foods; milk and donuts for breakfast.

Stress is high. Eyes are deeply bloodshot, whites are slightly yellowish and

dulled. Lips pale. Sensation of tightness along sternum. When fatigued, has

burning in chest and lungs, and difficulty breathing.

 

Tongue - Pale with paler, tender sides. Thick greasy yellow coat.

Pulse - 100 bpm. Right - superficial, slippery, rapid. Left - superficial,

thin, hollow, rapid.

 

Diagnosis - wood invading earth and generating stomach fire; liver invading

lungs; stomach fire rising to scorch lungs; blood deficiency

 

Treatment - Clear heat, strengthen and moisten lungs, strengthen kidney and

earth, calm liver, tonify blood, open chong mai and ren mai.

Lu-1, KI-27, Ten-17, TRen-12, Ren-4, LIV-13, LI-11, LU-5, LU-9, LU-7 (L), KI-6

®, SP-4 (L), PC-6 ®, LI-4, ST-36, SP-6, KI-3, LIV-3, LIV-2, ST-44. #36

needles, retain 15 minutes.

 

Eighth (and last) Treatment, September 10, 2007

 

Appears pale and weak, hunched over. Discontinued nexium as an experiment for 2

days, but continued taking it today after vomiting 2 times. Shortness of breath

with exertion. Queasy. Lungs not improved much since last treatment, except

mucus is clear, less thick, and scanty. Needs to sit and rest as much as 1 hour

during work. Occasional stabbing pain in stomach, lots of burping.

 

Tongue - Pale, slightly large, wet, sides slightly swollen. Thick greasy yellow

coat in center.

 

Pulse - 100 bpm. Right - superficial, slippery, fast; distal position is soft.

Left - Thin, rapid, medium depth, slightly slippery.

 

Diagnosis - Lung yin and qi deficiency with dryness from stomach yin deficiency

heat scorching lung.

 

Treatment - cup upper chest, clear heat, nourish yin, stengthen lung, downbear

stomach qi.

Ren-12, LI-11, LI-4, KI-6, LU-7, ST-36, SP-6, ST-44, LU-10. #36 needles, retain

20 minutes.

 

Breathing better after cupping.

 

Phone Call 2 weeks later and end of story

 

Patient went to hospital and required transfusions of 5 quarts of blood! Later

was diagnosed with leukemia, and told it was a “very survivable form“ with a

short course of treatment. Bone marrow donor sought, a few months go by.

Marrow donor found, but a mass is found in lung and biopsied - diagnosed with

valley fever. Marrow transplant delayed for removal of lung mass, antibiotics,

and healing. Bone marrow transplant performed, patient is put in

medically-induced coma due to severe weakness. Coma was ended in mid-April

2008, patient’s liver and kidneys are failing; placed on liver transplant list.

Diagnosed with graft vs. host disease, given meds to suppress this, but he dies

soon after.

 

Thoughts

 

This patient described being healthy and robust all his life, prior to the

summer of 2006. In biomedical terms, he had two major illnesses and a third

brewing - valley fever, leukemia, and a severe stomach problem - maybe an ulcer,

maybe cancer or something else. It bothered me that doctors had identified the

mass in his lung in the summer of 2006, and decided to do nothing about it. It

seemed they were more interested in ruling out what he did not have, than in

determining what he did have, and then treating that. As his illness went

through various twists and turns over time, more signs of blood deficiency

became apparent. Reading through his history, I am awed by the dreams of

bleeding to death he reported on his first visit. He had CBC tests at various

points through his illness, with no abnormal counts until September 2007, when

he was suddenly, severely anemic. I could see he was becoming more blood

deficient, but could not know it was leukemia.

 

I recommended herbs at various points, and most of the time, he refused them,

saying he “didn’t like to take stuff”. When he did accept them it was only

because he thought they would boost him enough for his 3-week vacation to Italy.

 

Until the last 2 visits, he had remarkable recovery and progress with

acupuncture treatments alone, but I never got to know whether his illness

resolved, since he discontinued treatment when he felt well enough to work (or

go on vacation), and then return only when severe symptoms presented again. I

believe the illness went deep into his body, predisposing him to the joint aches

and chills he had the following winter. I also believe it severely depleted his

reserves, qi, yin, blood, yang, jing. He was not interested in following

recommendations for rebuilding his reserves.

 

It is not clear to me how he developed such severe stomach trouble between the

first year and the second. This remains a puzzle, for which I have only

questions - was his stomach yin so depleted but not yet causing symptoms that

first year? Was it a result of too much intense stress? Did his initial

illness get lodged in the shao yang level? If I was presented with the same

case again, I would ask more questions and look more deeply for clarity.

 

Finally, the degree of breathlessness and fatigue might have been the biggest

clue of all. If there is not enough blood, the lungs don’t get enough oxygen.

Next time I see a patient with that degree of breathlessness, I will encourage

them to have their MD run more extensive bloodwork and track them more closely.

I will suggest they be tested for leukemia. Now I know what it looks like; it

is a bone-chilling lesson I will never forget.

 

How this looks to me in retrospect, is that the initial illness had weakened,

even drained him. The seeds for leukemia might have been there all along, and

his weakened state gave it an opportunity to present itself, especially with his

tendency to work himself to exhaustion and with high stress.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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