Solve the Medical Riddle: Her Broken Bone Isn’t Healing, First Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP and a specialist will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Kathy, age 51, is concerned because her broken toe doesn’t seem to be healing even though the injury happened three months ago.

As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Kathy told the PCP:

“I stepped off the dock onto my friend’s sailboat when I was visiting her in Florida and I heard a cracking sound in my right foot. I paid no attention until a few minutes later when my fourth toe started to hurt and swell. I Googled ‘broken toe’ on my phone and read about ‘buddy taping’. The site said I should tape my fourth toe to my middle toe so the middle toe would act as a splint. My friend had a first aid kit on board and she helped me with the taping. I was in a fair amount of pain, but I figured the toe would heal in a few weeks. That evening and for several days after that, I iced my foot and elevated it every so often. I hobbled around during my Florida vacation and then I started using a cane when I got back home. This all happened three months ago. My toe still hurts every time I put weight on my foot. I finally decided I ought to come to see you. Surely I should be better by now! Oh, and this is probably totally unrelated, but the tan I got in Florida hasn’t faded. If anything, I’m darker than ever. That seems kind of strange to me!”

The doctor delved deeply into Kathy’s medical history and did a complete ROS (review of symptoms) to find out what else might be going on that could give a clue to the diagnosis. A key finding was that Kathy has autoimmune ovarian failure with early menopause. She went through menopause at age 42 and never thought much of it as her mom was in her mid-to late 40’s when she went into menopause. Kathy used an estrogen patch as hormone therapy for a few years but she stopped when her hot flashes abated.

The Doctor considered osteoporosis because of the non-healing foot injury in a 51 year old with early menopause and referred Kathy for a bone density scan called dual-energy x-ray absorptiometry (DXA) or bone densitometry. This enhanced form of x-ray measures bone mineral density (BMD) and indicates whether there has been bone loss.

The doctor noted that Kathy takes thyroid medication for an underactive thyroid that was diagnosed a few years ago.

When questioned closely, Kathy admitted to more fatigue and muscle weakness recently. She had simply attributed these complaints to aging and trying to do too much. She also said she has mild nausea and she had lost about ten pounds since her last doctor’s visit. She said she just didn’t have much of an appetite any longer.

During the physical exam, the doctor learned that Kathy has diffuse hyperpigmentation even on surfaces not exposed to the sun such as her abdomen and buttocks. Also, her blood pressure was low for her at 90/60, which may indicate low fluid volume.

The doctor didn’t discover any more abnormalities other than a point of tenderness over the toe that Kathy had fractured, and mild generalized muscle weakness on neurologic exam.

The doctor ordered routine blood work. He then referred Kathy to an endocrinologist.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn the results of Kathy’s bone density test, blood tests, and to find our how the PCP and the endocrinologist continued the quest for a correct diagnosis of Kathy’s condition . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.