Just one more thing, doctor

Abstract

Introduction: One of the challenges family doctors face is the management of the unexpected. This case report describes the conse- quences of listening to a comment of "just one more thing, doctor..." Case description: A sixty year-old woman with a history of fibromyalgia, who was a frequent attender in a primary health care clinic, vi- sited her family doctor to present the results of diagnostic tests that had been requested at the previous visit. At the end of the consul- tation, the patient added that her husband had commented that she was not well and she reported memory loss, frequent episodes of losing her balance and falling, and more tension headaches. Neurological examination revealed asymmetric distal sensory loss, unsteady gait, a Weber test lateralizing sound to the right, diminished bilateral ankle reflexes and a Romberg test that was positive with a slight backward sway. Laboratory tests revealed vitamin B12 at the lower limit of the normal range and increased plasma homocysteine. Cobalamin replacement was initiated with partial remission of the sensory abnormalities after five months of therapy. Nine months later, the sensory changes returned to normal, with improved mood and memory and a decreased number of falls. Upper gastrointestinal endos- copy revealed atrophic gastritis, which indicated that lifelong treatment with cobalamin would be necessary. Comment: Patients with low-normal serum cobalamin may present with neurological abnormalities that respond to replacement thera- py. An appropriate response to the simple comment of "one more thing, doctor" was the key to diagnosis and therapy that prevented ir- reversible complications and improved the patient's quality of life.