Well as usual Julian nailed it on the head, but he cheated as I have used that same case as an illustration during this year's conference in NZ...........
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The question was "What do you do?", right.............
First you think differential diagnosis of "Abdominal pain, in elderly patient, with emaciation, with dry eyes"............algorythm......
As soon as a list of symptoms is presented, a list of possible pathologies MUST flash in front of your eyes; you all wrote some of them, drowned in an ocean of rubrics and remedies that should have come a lot later if at all:
Various tumours, ulcers, and gall bladder pathologies are the obvious ones but they have been excluded by the TOTALLY USELESS tests performed by GPs and specialists.
The only diagnosis that holds water, and is well described in every textbook, is intestinal claudication, where the superior mesenteric artery is partially occluded; as soon as some food reaches any part of the digestive system, it stimulates it, creates contractions and secretions, but they cannot be sustained due to the lack of blood supply, hence the PAIN (like angina pectoris or intermittent claudication, but in the gut); this lack of blood supply prevents also the proper absorptive function of the gut, hence the increased malnutrition on top of not eating due to the pain, and the dry eyes because of lack of resorption of the fat soluble Vitamin A.
Check your textbooks, it is frequent, it is classical, it is not a weird diagnosis where you have to be a "Sherlock Holmes" to find a rare gem...........it is really very common......and missed............
Now to CONFIRM your diagnosis, you EXAMINE the patient.
I put my had on her epigastrium, felt a thrill (murmur), synchronous with the pulse; no masses. Hand on the chest, no thrill; hand on the lower abdomen, no thrill.
Then auscultation: stethoscope on the epigastrium, rude 4/6 systolic murmur, indicating a tight arterial stenosis somewhere; steth on the chest, no murmur, it is not transmitted from the heart; steth on the lower abdomen, no murmur, it is not transmitted from the iliac or femoral arteries; steth on the back, no murmur, it is not coming from the renal arteries.
So the CLINICAL DIAGNOSIS, the one that interests us, is intestinal claudication, intestinal ischemia caused by a stenosis (narrowing) of the superior mesenteric artery.
Period.
The only test to CONFIRM this is a selective angiography.
So I phoned the GP, tried to be polite and not yell at him, sent the patient back; an angiogram was done the next week, confirmed the diagnosis, the stenosis was opened through balloon angioplasty and stent, end of the problem.
Patient came back for a courtesy visit, being able to eat, eyes less dry, no pain, gaining weight and able to go back to her previous life style, did not want any further treatment.
Why do I insist here?
Intestinal arteries are terminal (see anatomy course), meaning that they do not link/anastomose with others, and once they are completely blocked, you get gangrene of the bowel, which often ends in death despite surgery, where you remove almost all of the small intestine.
Say what you want, but no amount or quality of homeopathy can take care of this purely mechanical problem.
Conclusion:
1. even if the patient has been checked by MDs, do not trust their judgement: you just got one example, I have quite a few other horror stories; they did all the modern tests, but when I asked the patient when was the last time someone palpate her abdomen, that was 12 months earlier, and NOBODY auscultated her abdomen, which is basic diagnostic skill.
2. therefore, you need to know pathology and diagnosis for cases like that and for the ability to say: "this is not for me", but at the same time the ability to send to the proper therapist with clear guidelines and not, like her GP did to me, "well, I do not know what is wrong with you and how to deal with you, go see Joe the Quack, he will know" (his own real words, that has become my nickname in the conventional local world, but this case has also established trusting relationships with GPs......they chat between them too......)
3. as JW wrote, know what has to be treated right now; constitutions, miasms, etc, are very nice but maybe not right now..............you need a POSITIVE diagnosis, and only when everything has been eliminated (OK not in each and every case) can you talk functional, emotional, spiritual, etc,....
Basic, simple, classical knowledge and diagnostic skills, nothing sophisticated, nothing out of the common, it is all in the books, as I wrote the other day, gathering dust..............
My apologies if I come through as ranting, but this case and many others make me absolutely furious, raging at what I call malpractice.
Imagine what would have happened had this patient died under my "purely" homeopathic care: you can see the headline: "Careless homeopath kills a patient!!" and the like...........
Saying that "they" missed the diagnosis too would not help; taking on the care of the patient, you take the responsibility over; and as you know, we often come as the last resort.
So for the sake of our patients, we MUST be not only better, but the best.
This concludes my preaching for today..........
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Dr. J. Rozencwajg, MD, PhD.
"The greatest enemy of any science is a closed mind"