A collection of more than fifty hard-to-crack medical quandaries, featuring the best of The New York Times Magazine's popular Diagnosis column—now a Netflix original series
“Lisa Sanders is a paragon of the modern medical detective storyteller.”—Atul Gawande, author of Being Mortal
As a Yale School of Medicine physician, the New York Times bestselling author of Every Patient Tells a Story, and an inspiration and adviser for the hit Fox TV drama House, M.D., Lisa Sanders has seen it all. And yet she is often confounded by the cases she describes in her column: unexpected collections of symptoms that she and other physicians struggle to diagnose.
A twenty-eight-year-old man, vacationing in the Bahamas for his birthday, tries some barracuda for dinner. Hours later, he collapses on the dance floor with crippling stomach pains. A middle-aged woman returns to her doctor, after visiting two days earlier with a mild rash on the back of her hands. Now the rash has turned purple and has spread across her entire body in whiplike streaks. A young elephant trainer in a traveling circus, once head-butted by a rogue zebra, is suddenly beset with splitting headaches, as if someone were “slamming a door inside his head.”
In each of these cases, the path to diagnosis—and treatment—is winding, sometimes frustratingly unclear. Dr. Sanders shows how making the right diagnosis requires expertise, painstaking procedure, and sometimes a little luck. Intricate, gripping, and full of twists and turns, Diagnosis puts readers in the doctor’s place. It lets them see what doctors see, feel the uncertainty they feel—and experience the thrill when the puzzle is finally solved.
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About the Author
Lisa Sanders, M.D., is an internist on the faculty of the Yale University School of Medicine. She writes the monthly column Diagnosis for The New York Times Magazine, is the author of Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, and served as a technical advisor on Fox TV's House, M.D. She lives in New Haven, Connecticut.
Read an Excerpt
Just a Fever
“I think I’m losing this battle,” the fifty-seven-year-old man told his wife one Saturday night nearly a year ago. While she’d been at the theater—they’d bought the tickets weeks earlier—he’d had to crawl up the stairs on his hands and knees to get back to bed. Terrible bone-shaking chills tore through him, despite the thick layer of blankets. The shivering was followed by sudden blasts of internal heat and drenching sweats that made him kick off the covers, only to have to haul them back up as the cycle repeated itself.
You really need to go back to the ER, his wife told him. The frustration and worry were clear in her voice. He’d already been to the emergency room three times. They’d given him some intravenous fluids and sent him home with the diagnosis of a viral syndrome. He would start to feel better soon, he was told each time. But he hadn’t.
This all began nine days before. That first day he called in sick to his job as a physical therapist. He felt feverish, as though he might have the flu. He would drink plenty of fluids and take it easy and go back to work the next day. But the next day he felt even worse. That’s when the fevers and chills really kicked in. He alternated between acetaminophen and ibuprofen, but the fever never let up. He started sleeping in the guest room because the sweats soaked the sheets and the chills shook the bed, waking his wife.
After four days of this he made his first visit to the Yale New Haven Hospital emergency room. He was already being treated for a different infection. Three weeks earlier he’d developed a red swollen elbow and gone to an urgent care center, where he was started on one antibiotic. He took it for ten days, but his elbow was still killing him. He went back to urgent care, where he was started on a broader-spectrum drug, which he was nearly done with. Now his elbow was fine. It was the rest of his body that ached.
But his flu swab was negative. So was his chest X-ray. It was probably just a virus, he was told. The antibiotics he was already taking would kill just about any of the likely bacteria. He should just take it easy till it passed. And come back if he got any worse.
The next day his fever spiked to 106. And so he went back to the ER. There he found a mob scene—crowded with people who, like him, felt like they were sick with the flu. It would be hours before he could be seen, he was told. Discouraged, he went home to bed. A nurse from the ER called the next morning. Could he come back now that the ER was more manageable? He was happy to return.
He may not have the flu, he thought, but he was sure he had something. But the ER doctor couldn’t find it. He didn’t have any chest pain or shortness of breath. No cough, no headache, no rash, no abdominal pain, no urinary symptoms. His heart was beating hard and fast, but otherwise his exam was fine. His white blood-cell-count was low—which was a little strange. White blood cells are expected to increase in the setting of an acute infection. Still, a virus can cause white counts to drop. His platelets—the tiny blood fragments that form clots—were also low. That can also be seen in viral infections, but it was less common.
The ER staff sent the abnormal blood results to the patient’s primary care provider and told the patient to follow up with him. He’d been trying get in to see his PCP, but the doctor’s schedule was full. It was the worst flu season in years. When he called again, he was told that the soonest he could be seen was the following week.
The office agreed to order blood tests to look for Lyme and other tick-borne infections. This was Connecticut, after all. He dragged himself to the lab and waited for his doctor to call with the results. The call never came. In his mind, he fired his doctor. He’d been sick for over a week and they couldn’t see him, couldn’t even call him with the lab results he’d asked for.
He again went to the ER on Sunday, the morning after his wife returned from the theater and insisted he go back. His previous visits and lab abnormalities caught the attention of the physician’s assistant on duty that morning. She ordered a bunch of blood tests—looking for everything from HIV to mono. She ordered another chest X-ray and started him on broad-spectrum antibiotics, as well as doxycycline, an antibiotic for tick-borne infections. He was given Tylenol for his fever and admitted to the hospital. As he prepared to leave the ER, the flu test came back positive. He was pretty sure he didn’t have it; he’d never heard of a flu lasting this long. But if he could stay in the hospital, where someone could monitor if he got worse, he was happy to take Tamiflu.
The lab called again later that day to say that the test had been read incorrectly; he did not have the flu. But by then other results started to come in. It definitely wasn’t his elbow—according to the patient, the orthopedic surgeon who saw him in the ER, and an X-ray. He didn’t have HIV; he didn’t have mono, or Lyme; he didn’t have any of the other respiratory viruses that, along with influenza, had filled up much of the hospital. Yet, after a couple of days, the patient began to feel better. His fever came down. The shaking chills disappeared. His white count and platelets edged up. It was clear he was recovering, but from what? More blood tests were ordered, and an infectious disease specialist consulted.
Gabriel Vilchez, the ID specialist-in-training, reviewed the chart and examined the patient. He agreed that it was most likely that the patient had a tick-borne infection. The hospital had sent off blood to test for all the usual suspects in the Northeast: Lyme, babesiosis, ehrlichiosis, and anaplasmosis. Except for the Lyme test, which was negative, none of the other results had come back yet. Vilchez thought that given the patient’s symptoms—and his response to the antibiotic—it would turn out that he had one of them.
And yet, all the results for tick-borne infections were negative. But there were other tick-borne diseases, less common in the Northeast but still possible. To Vilchez, the most likely was Rocky Mountain spotted fever (RMSF)—though it’s much more common in the Smoky Mountains than the Rocky Mountains. The spotted fever part, the rash, was seen in most but not all cases. It’s unusual to find the infection in Connecticut, but not unheard of. Vilchez sent off blood to be tested for RMSF and to retest for the other infections. The following day the patient felt well enough to go home. A couple of days later he got a call. He had Rocky Mountain spotted fever.
The patient, it turned out, had the misfortune of experiencing fever and flu-like symptoms in the midst of a flu epidemic. Under these circumstances the question quickly becomes not What does he have? but Does he have the flu? Once you get to no, it’s hard to go back to the broader question.
For the patient, recovery has been tough. Though the doxycycline helped with the acute symptoms, it took months before he could resume his usual patient load at work. He just didn’t have the strength or the stamina to get the job done. He feels that the illness brought him as close to dying as he’d ever been. Indeed, RMSF is the most dangerous of all the tick-borne infections, with a mortality rate as high as 5 percent even with current antibiotics.
One thing he was certain about, however. He needed a new primary care doctor. And he got one.
Table of Contents
Introduction: Solving the Puzzle xi
Part I Burning with Fever
Just a Fever 3
The Flu That Stayed 8
Burning Up at Night 13
Sick at the Wedding 19
Forgotten Triggers 24
A Killer Flu 29
Part II A Pain in My Belly
Excruciating Episodes 37
Was It the Fish? 42
A Bad Stomach Gets Worse 47
A Hockey Stick to the Gut 52
Age of Embarrassment 57
Hurts So Bad 62
Suddenly Sick, Again 72
Part III My Aching Head
Changing Visions 79
It Started with Sinus Pain 84
The Elephant Trainer Gets a Headache 89
A Sea of Gray 94
Everybody Lies 99
The Worst Ice Cream Headache, Without the Ice Cream 104
An Icepick to the Head 109
Part IV I Can't Breathe
A Deadly Itch 117
Uphill Battle 132
Part V All in Your Head
Honeymoon in Hell 149
A Different Man 154
Unexpectedly Drunk 159
A River of Confusion 164
The Sadness Signs 169
A Terrible Madness 174
High-Pressure Crazy 179
Part VI Out Cold
Passed Out on a Saturday Night 187
Frequent Fainting 192
Cold Case 197
The Deepest Sleep 202
Faint of Heart 207
Part VII Strange Rash
Red Scare 219
Near Death at the Hands of Doctors 224
Old-Fashioned Skin 229
Red and Sore All Over 234
A Black Thumb 239
Line Dancing 244
Part VIII So Weak
A Terrifying Silence 251
Total Collapse 257
Fear of Falling 262
An Overwhelming Weakness 267
The Long Haul 272
Wasting Away 277
Missed Signals 282
Most Helpful Customer Reviews
This is an incredibly interesting collection of essays which first appeared in the New York Times Magazine Column. Each essay is a case in which a patient presents with mysterious symptoms. The doctors then do some detective work, with a little luck thrown in, which leads to a successful outcome for the patient. In a way, it kind of reminds me of the tv show House. I'm glad that they also included how the patient did after the diagnosis and treatment instead of just leaving the essay off at the diagnosis. If you're into medical stories/cases then I highly recommend this book. I read it a few essays at a time. "I received an advanced copy of this book and am voluntarily leaving a review."
This book had me thinking a lot about how miraculous our bodies are – and how medicine/diagnosis often needs to be a joint effort. Sanders, a doctor who writes for the NYT and has been consulted for House, splits this book into eight different sections that all start with a common symptom among the patients (Burning with Fever or Aching Head) for example. From there, each patient’s stories diverge from the original symptom and the doctors will race to find a diagnosis. We don’t get to know each patient personally – this really is about hearing their symptoms, learning what the blood work/other tests reveal about what’s going on in their bodies, and journeying along with the doctors as they determine the correct diagnosis/treatment for whatever is going on with them. This book in turns freaked me out (there’s a lot that can go wrong in the body!) while also making me reflect on the doctors and nurses who have come into our lives over the years and found diagnoses – in several cases, rare diagnoses, because they kept searching for what was causing the symptoms. You don’t read this book to get to know individuals (doctors or patients) intimately. You read it if your favorite part of House (or Royal Pains or Grey’s Anatomy) is when they’re figuring out what in the world is going on with their patient. Each story is very short and can be read in only a few minutes.
These short intriguing essays are as much mystery as medical. Yes, I know, but seriously- these well written tales are about real people with real problems that baffle both them and their doctors. Sometimes the answer to their pain is simple and sometimes it's more complicated and obscure. If you haven't had a chance to read Sanders in the New York Times Magazine, then you're really in for a treat. If you have read her (as I have) over the years this is a great opportunity to have her work collected in one volume. Think of this as short stories and dip in and out. Thanks to Netgalley for the ARC. You will learn from each essay.