Wellness Check at the End of My Workweek: Sicker than I Thought?

Caribou, Thursday night…

I am off tomorrow but I will still do a lot of computer work for my job and my maintenance of certification in family medicine. After my day in the field today, I sat down with the computer on my kitchen island, my informal home office. For formal occasions, I sit in my library with the Amish-built white bookcases behind me, filled with books of various vintage along with my antique microscope and medication bottles.

Two days ago I had seen one of my regular patients, a man in his early 70s with more than his fair share of health problems. He told me that for the past six weeks or so he had been extremely tired and weak with pain in his shoulders and upper arms and his knees and lower legs, as well as fairly profound weakness of just some of the fingers of both his hands.

I ordered a bunch of lab work, which came back with a constellation I’m still trying to make sense of. He has an elevated white blood cell count, an extremely high CRP, which is an early marker of inflammation, but a normal sedimentation rate, which is a more slow reacting inflammatory marker. He also has liver irritation, evidence of muscle injury, and because he had raised concern of Lyme disease, I got a negative Lyme titer.

Because of his profound fatigue, even in the absence of sore throat or swollen lymph nodes, I ordered some testing for mononucleosis and cytomegalovirus. Acute phase immune globulin for Epstein-Barr virus, IgM, was normal, but the IgG, which is later to react, was sky high. It can stay positive for many years after an infection, but not usually at those levels as far as I know

My first hunch was that he might have polymyalgia rheumatica, but with the evidence of muscle damage, it was probably more of a polymyositis. I had already started him on prednisone, which works for both. With the evidence of muscle damage, I called and left a message to stop his low-dose cholesterol medication. I also said I wanted to talk more, but he didn’t call back.

After my house calls today, I tried calling him again with no answer. This started to make me a bit worried. Maybe he had decided to go to the emergency room or something. I logged into the state database, but there was no emergency room visit and no hospital admission, no additional blood tests. But there was a note from the local ambulance. At 3 o’clock yesterday morning he had called because he slipped out of bed and couldn’t get up because of his weight and his muscle weakness. The EMS report stated that the doors were locked so they had to go back to the station and get equipment to break into the house, where they found him lying on the floor, conscious and alert, just needing help to get up and refusing transport to the emergency room.

My mind raced. Was he back on the floor. Was he OK or was he not? Was he even alive? Should I call the police and ask them to do a wellness check or should I just drive across town and check on him myself. I decided to do the latter. I put the doctor bag with my usual equipment in the back seat. I already had the big bag with EKG machine and all the other stuff in the rear of my SUV.

I got to his house, where all the windows were dark. I knocked on the kitchen door and the living room door and there was no answer. I went back to the car and was just starting to dial the hospital to see if by any chance he was in the emergency room. Then I heard his familiar voice, “who is knocking on my door?“

He let me in and told me the prednisone was working. He could move his shoulders normally. His legs were stronger, but his hands were still weak. He felt less exhausted.

We chatted about all kinds of things for half hour before I told him I needed to go home and take care of the animals.

I have to admit I didn’t know what I would find when I went to his house. I was very relieved that he was feeling better, but I still need a long-term plan and a firm diagnosis. He seems to have polymyositis, improved with prednisone, but will likely need additional disease modifying medication. I still don’t know if this was in any way triggered by his cholesterol medicine, by mononucleosis or even by an occult malignancy. I’m going to need to reach out to some specialists to move my workup forward. We just don’t have many of them in my part of the state. Fortunately, I have a network of specialists that I can consult with virtually. I wrote about this not very long ago. I’m so grateful I have that opportunity for backup as a country doctor in northernmost Maine in a county the size of Connecticut and Rhode Island combined with no rheumatologist and no full time infectious disease specialist - and, for that matter, no neurologist in case my patient’s scattered areas of weakness are manifestations of a polyneuropathy not explained by mononucleosis.

Sitting by the fire after supper, I’m still wondering how this all fits together. Primary care isn’t always easy…