Discussions By Condition: I cannot get a diagnosis.

HELP! not sure what's wrong???

Posted In: I cannot get a diagnosis. 17 Replies
  • Posted By: Smudger1986
  • June 10, 2009
  • 10:09 AM

Hi my name is David i'm a 22 yr od male from East London UK, i' a non-smoker and one day a week drinker, usually fit as i usually go gym and play soccer only been restricted over the last year due to my symptoms.

about 3 or 4 years ago i started getting tenderness in the centre upper/right abdominal region of my body, it sometimes feels bloated and is painful when touched, i went to my doctor who put me on a proton pump medication and done numerous blood tests on my stomach in which everything came back fine and the medication didn't make a difference, so i left it as it wasn't bothering that much and wasn't stopping me doing anything.

in May 2008 i started getting more symptoms i noticed whilst doing a maitenance night shift in which i'm unsure whether they are or not linked to the problem above they are: Headaches(light headedness & dizziness although not as common), Shortness of breath(restricted feeling in and around rib cage area), Heart Rhythms(palpitations, rapid beat especially with exertion, sometimes feels like beating out of chest), back ache between shoulder blades that radiates through to chest, constant blocked nose( usually only one nostril in which it switches sides, sometimes bleeds) Fatigue and weakness, although i've always been a bad sleeper.

i've had a chest x-ray and upper abdominal US all coming back fine ruling out lungs, heart, pancreas, gallbladder, spleen, liver, kidneys everything in that area, also had amylase, calcium, complete blood count, creatinine, c-reactive protein, electrolytes, ferritin, glucose random, ICP, iron, liver function tests, phosphate blood tests in which all came back fine and normal aswell, blood pressure is fine and when at rest heart beat is usually around 60-70 bpm.

i'm hoping someone can give me some help as i've been trying to self-diagnose myself as the doctors seemed to have give up, this is really starting to affect my quality of life and just want some closure on what's wrong with me, please help so i can finally put my mind at rest, it would be much appreciated thanx.

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17 Replies:

  • Have you had an upper GI and possibly a gastroscopy? It sounds like you might have the beginnings of acid reflux. These 2 examinations will rule that out. Thats surely what it seems like to me...
    ckanaan 33 Replies Flag this Response
  • i'm not so sure about Acid Reflux, my doctor ruled it out saying that the omeprazole medication he put me on would have helped it but nothing, i've also tried apple cider vinegar and that hasn't helped either.
    Smudger1986 2 Replies Flag this Response
  • 22y M -3-4 y ago tenderness in epigastric region-placed on PPI, gi tests WNLMay 08-headaches?, light-headedness, dizziness-dyspnea-palpitations-back ache between shoulder blades radiating to chest-blocked nose (one nostril, switches --> likely normal), occasional epistaxis-fatigue, weakness (bad sleeper)-non-smoker, occ alcohol-Pulse, BP WNL-Physical exam findings not availableInvestigations done (all normal)-CXR -upper abd US -amylase -CBC, CRP, lytes-LFTs-Other: Cr, ferritin, RPG, ICP, Fe, PO4 Analysis-The symptoms seem to suggest a cardiovascular cause (chest X-ray does not rule out cardiovascular causes, although it is an important investigation). An EKG would also be needed. It is not listed whether this has been done.-Interscapular pain may be referred from biliary tract, or from aorta. A normal ultrasound would rule out biliary causes, and amylase r/0 pancreatitis (although lipase is more specific). -Too young for angina? Still, needs to be considered. Exercise stress test.-Ehlers-Danlos? Marfan? STD? ?aortic aneurysm Conclusion-It seems that your investigations have been focused on gastrointestinal causes of pain, and these have been ruled out. These were, of course, necessary, and have ruled out a number of conditions, particularly cholecystitis, reflux esophagitis, and pancreatitis, which may cause your symptoms. -Epigastic tenderness, interscapular chest pain, and palpitation can occur due to cardiovascular causes, as can shortness of breath and light-headedness. I think a cardiovascular evaluation is warranted based on your symptoms. Initial tests would include EKG, CXR (already done), and possibly exercise stress testing. -If cardiovascular testing proves to be normal, then one would consider musculoskeletal causes ("restricted feeling in chest") or other causes such as anxiety.
    m3dh31p 69 Replies Flag this Response
  • Okay, I see nothing of your history and the findings to indicate cardiovascular involvement. Firstly, ischemic conditions in a 22 year-old healthy and physically active male would have specific and very remarkable implications noted on clinical investigation and the nature of his symptoms do not correlate with such manifestions in a patient so afflicted. The original complaint of pain in upper right quadrant with observed distention, particualrly in light of the other symptomatology described, would suggest duodenal stasis. When the duodenum becomes irritated to a chronic state, it roentgenologically (under certain imaging studies) shows early emptying. Duodenal stasis, which may be the result, frequently is associated with gastric dilatation that results in negative pressure. Subsequently, any air or gas that is within the lumen is sucked in through a patent cardia, and the patient complains of fullness and distention. The overdistended stomach frequently exerts mechanical pressure on the retroperitoneal portion of the duodenum, increasing the duodenal stasis. There may be in some cases a very marked discomfort a short time after eating and can be accompanied on occasion by colic pain which may extend to the right subscapular region, which may become unbearable to the patient and is sometimes erroneously interpreted as evidence of gall bladder dyskinesia on evaluation. Acute Gastritis is also a common misdiagnosis. Interestingly, the patient history will often but not always reveal that a sudden emission of air, which the patient refers to as belching, immediately reduces the overdistention and colicky pain to some extent. This is because the pressure is relieved on the retroperitoneal portion of the duodenum and it assumes its normal tone. The patient's discomfort is somewhat relieved and they may even describe a feeling of wellbeing. This reaction can be cyclic during exacerbation of the event, sometimes with repeated acts of belching that over time reduce the discomfort to manageable levels. Several factors accompany this condition, one of which is the near constant sensation that the musculature at the rib directly proximal to the duodenum feels bruised or sore and, additionally, there are nearly always underpinning emotional factors which the patient may or may not admit on elicitation of history. These emotional factors, however, are sometimes evident as somatoform, demonstrated in characteristic patterns being described by the patient as physical symptoms, ie headaches, light headedness & dizziness, shortness of breath or difficulty achieving inspirational breath, palpitations, tachycardia, scapular or parascapular pain, fatigue and weakness, sinus conditions which do not correlate with seasonal rhinitis. Interestingly, the symptoms of duodenal stasis can sometimes mimic the hyperacidic conditions associated with reflux disease but proton pump inhibitor therapy is seldom successful, with mixed results at best. The complications of duodenal stasis can oftentimes be attributed in part to aerophagia, or the swallowing of copious amounts of air, which ultimately aid in producing the characteristic distention. My suggestion at this point is to obtain referral to a gastroenterologist to consider performing gastric emptying studies with particularly attention to the duodenum. Secondly, your doctor should consider treating the condition from the standpoint of reducing clinical anxiety. Such efforts typically correlate with a reduction in physical symptoms. Again, I see nothing of the symptoms to suggest cardiovascular involvement and certainly nothing to do with cell phone antennas of all things. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • Dear JCottleMD, I had prepared a lengthy and referenced response to your post, but then deleted it after reading many of your old posts, realizing that it would only feed your already over-inflated ego, and lead to an even longer and more convoluted rebuttal. Do not get me wrong, I am all for constructive criticism, but you come across as abrasive. Do you mean to imply, for instance, that my suggestion of a cardiovascular problem is as preposterous as the suggestion of cell phone antennas! I have noted that you assume that you and a select few on this forum are the only licensed MDs (although I cannot find your name as a licensed MD on any search) committed to "first do no harm" and the rest of us are buffoons dispensing harmful, or at best, inaccurate advise and playing "internet doctor." I will not stoop to your level, but I have noted some of your old posts in which your advice would be considered downright ignorance (though a lay person could hardly tell given your faculty with language). In this age of the expansion of medical knowledge and specialization, none of us can be experts in every condition and knowledge gets dated rather fast. I think the purpose of this forum is to help people, and some of us prefer to do so without screaming out our unverifiable credentials while still remaining anonymous. In summary, then, all I have to say is this: I agree with you that cardiovascular involvement is unlikely in this case, and I stated so. But I respectfully disagree with your assertion of "duodenal stasis" as the problem in this case. Duodenal stasis is a rather archaic and nebulous term which could include a whole host of conditions such as megaduodenum, duodenal atresia or stenosis, inflammation of the duodenum, and SMA syndrome. You presented a lengthy pathophysiologic dissertation on the effects of duodenal stasis as though it were a discrete clinical entity, and pretty much the only symptom it explained was epigastric pain and distension. Most of the other symptoms including headaches, dizziness, dyspnea, palpitations, interscapular pain were ascribed to vague "emotional factors" presenting as "somatoform" symptoms. I do agree it was a brilliant thesis explaining everything while explaining nothing. Not awaiting your lengthy convoluted response, Respectfully, m3dh31p
    m3dh31p 69 Replies Flag this Response
  • Well, at 85 years old, there's not too much about me that's not "archaic." You take offense merely by virtue of what you wish to portend and I see nothing of my actual comment that indicates such an egregious comparison. Incidentally, there is nothing in your "notes" wherein you state cardiovascular involvement to be unlikely but it's purely academic. My comments were intended strictly for the individual posting the inquiry and not intended as fotter for those feeling pierced by arrows regardless of where they're aimed. As you rush to take my parking space, I'll simply echo the words of famed actress Kathy Bates, "I'm older and I have more insurance." If you wish to "help" people, join the Salvation Army. Medicine is about the constant struggle to overcome illness and disease in humans. There is no adorning pride to bestow upon you for openly proclaiming allegiance to the hippocratic oath. I'm also quite taken with your statement suggesting that I have an "over-inflated ego," while simultaneously you demonstrate all the requisite signs of somehow believing yourself to be central to the content in my postings. No one need point you out, for you do it only too well entirely of your own accord. Although I wince at the very thought of providing guidance in this instance, I would suggest that you step back and take a breath my young colleague. Nothing of this forum is about you. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • Nothing in my taking "offense" is personal. Rather, it is about your dismissal of any possible cardiovascular cause with a flourish of your magic wand as another crackpot theory akin to some EM radiaton theory, only to be replaced by some implausible theory of your own. Of course, you do have the right to implausible ideas as "blaze" has to hers. Regarding your notion of medicine, it was Walsh McDermott (in earlier editions of Cecil Textbook of Medicine) who defined medicine as "a human activity undertaken for the benefit of others whether in the area of public health, 'statistical compassion,' or in the care of the individual patient." That, to me, defines helping others. What I found most revealing about your post was the phrase "as you rush to take my parking space." You deny an over-inflated ego, but I am sure you're not archaic enough to not know what a Freudian slip is. Trust me, your "parking space" is the very least of my interests, so you may rest secure/assured. Having said that, I am willing to put all of this nonsense aside and raise the white flag. I do value your "guidance" and opinion, as I make no claim to infallibility. I do believe you are performing a genuine service (whether you consider it a service/help or not) here, and I respect that. I am willing to concede that the misunderstanding was entirely on my part, and I hope you will see fit to correct me when you deem I am wrong (and I, on my part, will abstain from "overreacting"). I absolutely agree that nothing on this forum is about you and me, and everything about the people who come here seeking help or advice. In conclusion, please do not wince, step back and take a breath yourself, and continue with your valuable contributions. Respectfully, m3dh31p
    m3dh31p 69 Replies Flag this Response
  • Written correspondence can sometimes represent the devil's own quill, with a great deal of human inflection lost to mere interpretation. I believe you may have misinterpreted my analogy. At 85, my thrill and absolute privilege of practicing medicine has passed and indeed, my participation altogether is coming to a close. A newer generation is taking my parking space, so to speak, an unavoidable reality that I dwell upon with envy to the extent that I would do it all again a thousand times over if somehow it were only possible. I simply reserve the right to remain purposeful and retain my dignity as long as I can draw a breath.To close on the topic, the notion of help is centerpiece to the patient's perspective alone. As physicians, what we do best in the selfless interest of patient care is to attempt with all dispatch to absolve them of the illness and disease which plagues to no end. Help in such matters is of little consequence if incomplete.Forums such as this exist as testimonial to certain failures within the industry of medicine that surreptitiously sidelines the misunderstood, the frustrated and the financially deprived in favor of an ever-changing mainstream clientèle, whose healthcare is no longer under the direct guidance of the medical community. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • This is stating the obvious, but just for the record: Smudger1986, if you are reading this and are confused by the clouding of issues on your thread, I would like to state that JCotterMD's opinion should be considered the expert opinion, the one you should take most seriously. I realize that JCotterMD has a distinguished record on this forum and does not need my endorsement, but I just wanted to set the record straight.
    m3dh31p 69 Replies Flag this Response
  • I'd like to thank you both for your posts, i will definatly be taking the information use have given me on both posts into account, i understand and greatly appreciate that you both care a great deal in helping people and passing on knowledge and experiences. Unfortunatly i'm in NZ at the moment and due to my symptoms getting worse(especially the dizziness and vertigo), i'm looking to fly back to the UK to investigate my problem further, i'll will keep you posted Kind Regards
    Smudger1986 2 Replies Flag this Response
  • JCottleMD's initial response is heavily influenced by an article written by Sidney A Portis over 60 years ago. So much so, he has quoted parts of it. Portis was an early champion of psychosomatic disorders. Now there is no doubt that people do 'worry themselves sick' and nervous indigestion is nothing new, but Portis and his disciples take things a stage further. They suggest that anxiety is a major underlying cause of many illnesses. This of course can never be proven and it is about as useful as saying your negative energy fields (or whatever) are out of kilter. While I agree that you might have an intestinal problem and JCottleMD's suggestion to see a gastroenterologist is a good one, his suggestion to have you treated for 'clinical anxiety' is not. The digestive system is complex and problems are not always easy to identify. To suggest this as a possible cause to you doctor would pigeonhole you as neurotic and to take the urgency away from treating you properly. JCottleMD's suggestion that such treatment typically correlates with a reduction in physical symptoms is misleading. It either correlates or it does not (typically is not a statistically defined term) and it is fair to say that no such data exists for the population at large. That said, it is worth remembering that worrying is not going to help matters. But that should be about as far as it goes. You could do well by improving your sleeping patterns also.
    Anonymous 42,789 Replies Flag this Response
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  • Well, subsequent to all the tests which were listed as producing no evidence of an organic basis for his symptoms, I'd be interested to know what tests this individual should further have conducted and what systems evaluated? I'm all too familiar with the notion by some that if the first full roundhouse of diagnostic tests don't reveal the cause, then run a second and third in hopes of a different result. Even if the tests are negative, it may even be suggested that the tests themselves could be questionable and need to be either repeated in a different clinical setting or through an alternate lab. While I agree that organic causes should first be ruled out in all instances of suspicious physical symptoms, alternative underlying factors should be entertained regardless of whether it crosses out of the hands of the allopathic physician. While not entirely aligned with Portis, I indeed concur that physical symptoms of a considerable intensity can be manifested in the entire absence of clinical disease. To suggest that such phenomenon is limited to an "upset tummy" is extremely shallow and equates with an arrested position that if not organic, then a cause simply doesn't exist. Toddlers tend to demonstrate the same perspective in wondering where mommy actually went when hiding her face in her hands. There are a good number of postings throughout the forum wherein descriptive content demonstrates quite similar symptomatology and in the presence of such evidence, the position of the most recent response would suggest that clinical medicine is demonstrating an awfully consistent inability to determine the underlying organic cause. I've certainly lived and practiced long enough to recognize a blinders-on approach, for the individuals who most often post to this particular forum catergory have been tested ad nauseum. I can only wonder what value repetition holds for these people as patients and why investigation of somatoform factors "should not" be investigated, while alternatively stating that merely improving sleep patterns would somehow indicate the appropriate direction. Lastly, I'm amused at the suggestion such individuals should adamantly refrain from discussion of somatoform with their primary care doctor or specialist in order to avoid being construed as neurotic. I liken that perspective to refraining from attendance at church to avoid being associated with sin. It is statements and positions like this that actually produce forums of the heading "I cannot get a diagnosis." To some clinicians and practitioners, it simply means that patients just aren't trying hard enough. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • I think JCottleMD may have won yet another round. It does make me wonder if as doctors, you are more intersted in helping the person who needs help or if you are just going after each others throats. Cmon guys. isnt this going a little to far off the subject. I mean, really. Ive never actually signed up on this site but its a shame that my first time is to say im disappointed. I dont know KNN or m3dh31p but dr Cottle has been on here for a pretty long time now and i will admit that i dont always agree with him. BUT i also see that he takes his time in trying help people on here and most important is that the response from people has been very good and it seems to have helped most of the time. i mean, what else do you people expect from a free medicine forum. by the way JcottleMD I visit here and on another website and i just want you to know that beside what is being said by some people i think your doing a really really good thing by giving your time on here to help. im a big fan. just wanted you to know Karen O
    Anonymous 42,789 Replies Flag this Response
  • JCottle, my concern about discussing somatoform symptoms is that it allows a convenient diagnosis for a busy doctor. A diagnosis that can never be proven and the treatment of which involves a trial and error approach. Moreover, if the treatment fails, then the inevitable response is to 'double the dosage', or try something else as well, rather than doubt the diagnosis. You only have to see the number of posters on fora such as this to realise the plethora of pills that some patients are given. This should never be. I suppose your analogy with church depends what you mean by sin in the first place. For example, the Church of Satan has a very different moral code to that taught in The Bible. Neither of us is qualified to judge which is right and which is wrong, however.In terms of digestive problems, we are pretty complicated beasts. Just because there is nothing mechanically wrong, such as a tumour, it doesn't mean to say something isn't working properly. The medical profession is slowly becoming aware of the importance of balancing the gut flora (and the over-prescription of broad spectrum antibiotics), as illustrated by the response to C. Difficile, for instance. Knock the digestive system off track, and there are all sorts of secondary symptoms caused by malabsorption, deficiencies, etc. And let us face it, a great many of us have somewhat less than ideal diets.There are a great many quacks in the field of nutrition and I do not intend to trumpet their cause. But I would suggest that Smudger might consider a dietary analysis (a proper one) with regard to identifying a suitable diet and/or potential food intolerances. But I would rather such an approach was made through qualified medical channels. A stool analysis might be a good idea also (depending on Smudger's history).Of course, there are bizarre symptoms that can be triggered by an illness. For example if a patient suffers from periodic vertigo due to an unidentified (but real) cause, then he or she can panic (i.e. increase adrenaline production) understandably in certain circumstances. To then treat that as a somatoform disorder is akin to putting thicker carpets in your car because there is a rattle beneath. The symptom might be cured but the cause still exists (and it could be brake pipe or whatever).No doubt there are a lot of people out there that make themselves ill, but to consider somatoform disorders as a primary cause of illness is little better than telling patients they have a negative energy field (or whatever).RegardsKNN
    Anonymous 42,789 Replies Flag this Response
  • You seem to profess knowing the mind of the physician. I, for one, never allowed a patient to set the stage for a "convenient" diagnosis and I take exception to the fact that physicians are regularly characterized on this forum as aloof morons whose primary gain lies well outside the practice of medicine, that we're basically ignorant to the more technically advanced insight of alternative and herbal medicine and that we consistently fail to properly evaluate patients by not running the absolute gamut of diagnostic tests deemed revelvant, repeated tests, tests by special literate doctors and tests to validate the tests. Yes indeed, as physicians we're the absolute moronic scurge of the medical industry and should establish a network wherein the monkey guides the organ grinder. And I do believe if I hear one more postulate that virtually everyone on this forum needs to have their stool checked for c. difficile, I'll scream if I still have the chords to do so at my advanced age. All one needs to see is a sign of GI dysfunction and it's off to the para-practitioner to have your stool checked for an abundance of flora gone wildly out of control, not withstanding the added notion that a candadiasis infection is lurking within. That is not the practice of medicine, but merely the demonstration of the carpetbagger and peddler, dousing with oils, shaking rattles and exorcising bad spirits. And as a retired neurologist with more than 40 years of previous experience, that you propose to lecture me on the "complexity of the human beast" tells me volumes of your apparent naive encroachment upon matters that never invited your scrutiny. And incidentally, panic is not induced by epinephrine production. Before you dismiss the nature of any given physiological response, you need to first understand it. As for the plight of the young man who originally posted inquiry and whose circumstances have since become lost to an ulterior cause, I can say here with immutable confidence that invoking all sorts of quasi-medical tests to measure bacteria and yeast will do nothing but empty his wallet. But then again, that's the idea for the holistic practitioner and herbalist who can't meet the competency level for reimbursement of services. It is the never-ending drive by persons such as yourself to reduce the "complexity" of human illness to a level wherein treatment consists of balancing intestinal flora by feeding them dandelions and mint leaves. You cite "complexity" and yet subscribe to primitive notions for a cure. To close this thread, I am entirely disinterested in what you believe to be treatable or even identifiable. My comments on this forum are strictly intended to provide response to the individual making original inquiry. I'm not here to listen to sideline philosophy about how the digestive system can "get knocked off track" as though such a descriptive somehow paradoxically represents clarity to what the medical community has failed to previously comprehend. My time is far too valuable to lend courtship to someone pretending to discuss differential diagnoses. As it has become nothing more than a nusiance, I will no longer entertain arguments or wayward dialogue concerning any comments I make to persons seeking medical information on this forum. If you disagree with my posting, then state your case, write a book or visit Oprah, but I've grown tired of the senseless rebuttle that serves no purpose whatsoever for the person seeking help. You couldn't stand among my former peers if you had shoes the size of Everest. I can assure you that I have absolutely no obligation to justify my position or comments to you or anyone else on this forum. I no longer care to be willing audience to obvious disillusionment. J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • To all concerned, I had no intention of going after anyone's throat. There was a miscommunication (pardon me for being human and making a mistake) and I settled it with JCotterMD. I also believe I made my position crystal clear as far as the original poster (Smudger1986) is concerned. Raising this issue again and again is becoming like picking at a scab. I consider this matter closed. Thank you.
    m3dh31p 69 Replies Flag this Response
  • Well I disagree with JCotter still. If he was up to date in the field of modern medicine, he would be aware that there is a national health service in the UK and Smudger would not be emptying his wallet by suggesting stool tests, etc. In any event, it would be for the gastroenterologist to decide (and he would come free too). I can't see a mention of a gluten intolerance test (which is almost routine these days) and this should be carried out if it hasn't been done so already.My concern with JCotter's response is that knowing virtually nothing about the patient or his history, he thinks he can recommend discussing a somatoform disorder with his doctor quoting a 60-odd year old paper word for word in parts: http://www.psychosomaticmedicine.org/cgi/reprint/6/1/71.pdf. I take my hat off to his seemingly elephantine memory.In his latest sphinx-like response, he has reversed what I said about panic causing adrenaline secretion to adrenaline causing panic, to try and discredit what I said. He also misquoted me with regard to C.Difficile. However, it might be that he is just reading what he wants to see.My advice to Smudger remains. That is to speak to his GP about seeing a gastroenterologist and/or nutritionalist (who would also come free) and to dismiss JCottle's suggestion about discussing somatoform symptoms.
    Anonymous 42,789 Replies Flag this Response
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