Think Like a Doctor: A School of Red Herrings

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

The Challenge: Can you figure out what is wrong with a 29-year-old former volleyball player who develops some odd aches and pains and a swollen foot?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to take on a difficult case and offer their solutions to a diagnostic riddle. This month's case revolves around an athletic and previously healthy 29-year-old woman who developed a pain in her groin, a swollen foot and ankle and a slew of lab abnormalities. We will provide you with many of the notes and tests from the many doctors who saw this patient.

The first reader to provide the correct test to make the diagnosis gets a signed copy of my book "Every Patient Tells a Story" and the satisfaction of unraveling a tough tough case.

The Patient's Story:

"Is your blood pressure always this high?" Dr. Becky Miller asked the young woman who had come to see her.

Until recently it had been fine, the slender 29-year-old told her. It was kind of crazy because she'd been healthy her whole life, the young woman continued. But these past several months she'd been seeing doctors almost weekly, and it seemed like every time anyone checked, her blood pressure was high.

Dr. Miller was the newest specialist the young woman had been sent to since her ordeal began eight months earlier. It started innocuously enough. She'd enrolled in a new Pilates class and somehow injured her left hip. As a high school athlete and, briefly, a professional volleyball player, she knew the ache of a pulled groin muscle, but this felt worse — a lot worse.

Walking hurt, even sitting hurt; exercise was impossible. She asked around and found an orthopedic surgeon in her Los Angeles neighborhood. He diagnosed her with a grade 2 sprain in her groin muscles and sent her for physical therapy. That didn't help. Then several weeks in, with her hip still bothering her, her left foot and ankle swelled up.

A Long List of Doctors:

The young woman went to her primary care doctor. He was the first to take note of her elevated blood pressure. Let's keep an eye on that, he told her. He wasn't much concerned with the swelling; she should just take it easy and use compression stockings when she needed them.

That didn't sit right with her. She felt like this was more than just the pulled muscle, so she went to her endocrinologist. He had helped her a couple of years earlier when she'd had irregular periods. Back then he figured out that she had too much of a hormone known as prolactin, which was messing up her menstrual cycle. An M.R.I. of her brain showed a tiny spot on her pituitary gland, the likely cause of the excess hormone. He put her on a medication called bromocriptine to block the prolactin and her periods improved, though they were still irregular.

The endocrinologist wasn't sure what had caused her swollen foot. He ordered an ultrasound to look for a clot in that leg, but no clot was found.

He ordered a CT scan of her abdomen and pelvis to see whether something might be getting in the way of the blood flowing back into her heart. No obstruction was found, but the scan did reveal that her spleen was somewhat enlarged.

The endocrinologist sent her to a G.I. specialist, who scoped her. He saw some gastritis, but nothing that would cause a big spleen. However, a blood test revealed that she had too many red blood cells — an unusual finding, especially in a young woman who was still menstruating. So he sent her up the street to Dr. Becky Miller, a hematologist at Cedars-Sinai Medical Center.

The Patient's History:

When the patient walked into Dr. Miller's cheerful waiting room that morning, the first thing she noticed was that she was the youngest patient in the office by a good 20 to 30 years. That scared her a little.

Still, Dr. Miller's cheerful manner and brightly colored crocs put her at ease. The doctor led her to a couple of armchairs in the middle of a homey office, and she launched into her by now well-rehearsed story about her symptoms, doctors and tests. Dr. Miller paid close attention, nodding and jotting down notes in the pad on her lap.

When the doctor examined her, she seemed quite surprised by the high blood pressure reading. The patient was quite tall, 5-foot-10, and slender, 150 pounds, with an athletic build. No, she told the doctor, she'd never had high blood pressure until her doctor had noticed it earlier that year.

The young woman looked quite healthy. She had a couple of tattoos on her back and arm. And some tenderness in the upper left quarter of the abdomen, where her spleen was located. Her left ankle was still a little swollen. The rest of her exam was normal.

Some Unusual Lab Results:

Dr. Miller had already reviewed the lab test results obtained by the gastroenterologist; they showed that the patient had a hematocrit of 50. Normal, for a woman, is usually up to 40.

The labs sent to Dr. Miller can be seen here.

Dr. Miller first considered causes of the patient's elevated hematocrit and enlarged spleen. She was worried that this was some type of cancer. Could this be polycythemia vera, an abnormal proliferation of red blood cells? Or was this leukemia?

She sent blood off to be tested for these illnesses, and when the results came back negative, she sent the patient for a bone marrow biopsy. She was reassured when that was unrevealing as well, so she turned her focus to the other medical issue: the patient's relatively new high blood pressure.

You can see Dr. Miller's note here.

Looking for a Cause of High Blood Pressure:

High blood pressure is certainly common. One out of three Americans have it, and for well over 90 percent of them, no cause will be found — a condition called essential hypertension. Many of these individuals will need lifelong drug treatment along with a low-salt diet and regular exercise to prevent complications from their disease.

However, in 5 to 10 percent of cases, high blood pressure has an underlying and, more importantly, treatable cause. Address the cause, and the high blood pressure will usually resolve. The trick is to identify those few who have high blood pressure as a symptom of another problem from the many who have essential hypertension.

This patient was at increased risk for hypertension — her father had it. Still, could some medical problem be causing her blood pressure to rise? And if so, was it also linked to her swollen ankle and high red blood cell count?

The doctor started the patient on an antihypertensive medication, lisinopril, and began looking for something that could have made this young woman's blood pressure rise. Was there a diagnosis that could make all these symptoms make sense?

Feeling the Pressure:

Medications are the by far most common cause of an elevated blood pressure. Many everyday over-the-counter drugs, including painkillers like ibuprofen or decongestants like Sudafed, can raise blood pressure. So can alcohol or stimulants like caffeine, nicotine or cocaine. Ordinary prescription drugs like antidepressants, Ritalin or birth control pills can too. But this patient told Dr. Miller that she took none of those drugs, rarely drank alcohol and never smoked.

In children, the most common cause of high blood pressure is a narrowing, or coarctation, of the aorta. If the condition is not found in childhood, it will continue to cause high blood pressure in adults. A difference in blood pressure between the left and right arm can suggest this problem. This patient's blood pressure was the same in both arms.

Another treatable cause of high blood pressure is narrowing of the smaller arteries leading to the kidneys, but a CT scan of the abdomen showed normal vessels.

You can see the report of the CT scan here.

Finally, some diseases cause excess secretion of body chemicals like thyroid hormone, adrenaline or cortisol that can raise blood pressure. The hematologist sent off tests looking for any of these, and when several came back abnormal, Dr. Miller sent the patient back to her endocrinologist.

You can see the results of the testing that Dr. Miller ordered here.

The endocrinologist ordered several tests to try to figure out what was going on. One of them was quite revealing.

Solving the Mystery:

Now I ask you, gentle reader, if you could order only one test to figure out what was wrong with this patient, which test would you order to lead you most rapidly to the right diagnosis? And what is the correct diagnosis?

I'll post the answer tomorrow.

Rules and Regulations: Post your responses in the comments section. The correct answer will appear Friday on Well. The first person to get the correct test and diagnosis is the winner and will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Updated, Friday Jan. 17 3:50 p.m. | Thanks for all your responses! You can read about the correct diagnosis at "Think Like a Doctor: Red Herrings Solved!"

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