A 36-year-old man showed up to the emergency department of the Massachusetts General Hospital, severely unwell from a puzzling set of conditions. He had abnormalities in his lungs, intestines, blood, liver, and lymphatic system—and, of course, no single clear explanation. His case was such a riddle that a master clinician with an expertise in clinical reasoning was called in to help unravel it.
In a case report published today in the New England Journal of Medicine, the expert and the man's other doctors lay out the masterful medical deduction that explained his remarkable case—which had an entirely unremarkable cause.
It all started about two weeks before his hospital visit. A mild, dull pain had developed in the patient's right lower abdomen and back. Nine days later, a fever and body aches also developed. The next day, he went to urgent care, where clinicians gave him intravenous fluids and an intravenous pain reliever. His abdominal pain went away, and he was discharged. But the pain returned over the next few days, and with it came nausea and vomiting. He then started coughing and having trouble breathing.
Complex case
The day before his hospital visit, he went back to urgent care. He now looked unwell and his eyes were yellowing, his heart was racing, and his blood pressure was worryingly low, as was his oxygen saturation, at just 85 percent. Clinicians could hear crackling in his lungs, and his abdomen was more tender than ever. They sent him to the emergency department.
There, doctors confirmed what the urgent care had found, noting he was also coughing up tan mucus. They also looked at his medical history, which was relatively short. He was born in Central America, but he had lived in the US for 16 years. He worked in construction, lived in a Boston suburb with his partner and two children, and didn't seem to have any medical problems except a history of alcohol use disorder. He typically drank four to five beers a night during the week and up to a dozen a day during the weekends, though he said he hadn't been drinking during his illness.