iStockphoto

“It must be a full moon—this patient has the weirdest symptom ever!” Kate, my intern, dropped into the chair across from me, looking haggard. We were early into the morning shift at our hospital’s walk-in clinic, where patients drop in with anything from runny noses to previously undiagnosed cancer, and already we were running late. Kate had been in with our second patient for 30 minutes. That was much longer than we had anticipated, since the reason the front-desk clerk had noted for his appointment was simply “hand problem.” Sounded innocuous enough. I asked Kate what the weird symptom was.

“He says his hands are possessed,” she said. “According to him, someone or something is forcing him to clench his hands—and he can’t make it stop. I couldn’t get him to quit talking about his possessed hands.” But Kate thought the patient’s delusional behavior was the least of his problems. “His legs are swollen and his lungs are full of fluid,” she explained. “I think he’s got some heart failure.”

As doctors, we’re all taught to pay attention to the chief complaint—the patient’s reason for coming to see the doctor—and to interpret what we find to explain it. In this case, though, Kate had astutely picked up on a potentially serious problem unrelated to the chief complaint, which sounded like something outside the bounds of the kind of medicine I practice.


I went in to the examining room to take a look at the patient with her. His name was Andrew and he looked older than his 60 years. He was ill-kempt, pale, and nervous and shifted constantly in his seat. As Kate had noted, he had swollen legs and was breathing with difficulty—classic signs and symptoms of heart failure. And, as she had noted, he didn’t care in the slightest about those symptoms; he just kept talking about his hands. “I’m telling you, doc, they aren’t doing it now, but somebody’s moving my hands without my wanting them to!”

I examined his hands carefully, as Kate had before me. No tremor, no numbness, no weakness. He could hold them still without any difficulty. We performed a standard set of tests of the nerves controlling his eyes, facial muscles, and neck; tested the strength in his arms and legs as well as his hands; and watched him stand and walk: all normal. No problem that we could see.

Looking through the chart, I saw that Andrew had a long history of anxiety, reclusiveness, and obsessive-compulsive behavior. Maybe, I thought, this obsession with his hands was part of that problem. We explained to him that we were worried about his heart and told him to go straight to the laboratory to check his blood count, kidney function, and heart function, and then come back to us. He grunted affirmation and trundled out.

When we finally caught up with the morning’s patients, we looked for his lab results on our electronic chart. But he’d never gone to the lab, and he wasn’t in the waiting room. “I guess he didn’t like our advice,” Kate said ruefully.

Two days later, I saw his test results pop up in my chart. At first I thought he’d come back to the clinic to finish the evaluation, but then I saw that the results were coming from the hospital’s emergency department. Apparently he had come in with the same complaint about his hands but had looked sick enough to get seen right away in the emergency room. And the lab results were coming up with exclamation points next to the numbers—a sign of values far outside the normal range.

For a moment, I had a terrible feeling of missed opportunity. Did he go home and have a heart attack? Should we have sent him directly to emergency two days before, instead of letting him out of our sight to go to the lab?

The numbers didn’t indicate a heart attack, however. Rather, he had the most severely low blood calcium level I had ever seen. When the amount of calcium in blood is measured, it usually amounts to 9 to 10 milligrams per 100 milliliters of blood. His was only 5 milligrams, a dangerously low level.