Summary and response to the New York Times Well article: Think Like A Doctor: Limping Along
We present a succinct overview of the case presented in the New York Times article and discuss how medical algorithms can assist in coming up with the correct diagnosis as well as clinical workup and treatment plan.

A 2-year-old male with developmental delay and autism is seen in the emergency department for increasing frequencies of falls and apparent pain with ambulation (left leg) over the past few months. He had been seen by his pediatrician previously, with reassurance provided to the mother that the gait was normal for a toddler. The child had a very picky diet, only eating peanut-butter crackers and strawberry Pop-Tarts. His only home medication was Miralax for constipation. There are no pets in his home he has not traveled recently.

There was a recent febrile upper respiratory infection and the child had other febrile episodes which the mother attributed to teething. There was no weight loss, hematuria, dysuria, nausea, vomiting, cough, or abdominal pains.

An x-ray of the left leg showed a linear lucency anteromedial tibial metaphysis. Initial laboratory evaluation revealed a normal CBC, normal CRP, slightly elevated ESR (33). CMP only showing slight abnormalities with sodium of 133, bicarbonate of 19, and AST of 44. Serum CK was normal as well.

The patient had a very long inpatient workup that included numerous pediatric subspecialties:  malignancy, infection, non-accidental trauma, histiocytosis, and others were considered. With each differential on the list ruled out, the etiology for the child’s diagnosis came into light when a petechial rash was noticed on the lower extremities and bleeding was noted on the gingiva.

When his extremely limited diet was considered, a nutritional workup revealed the diagnosis:  scurvy.

Utilizing medical algorithms, the patient’s primary care physician could have utilized Findings in a Child with Musculoskeletal Complaints Suggesting an Occult Malignancy to determine if the presenting leg pain/difficulty with ambulation warranted a further workup.

The extremely broad differential diagnosis in this case are prime examples of how medical algorithms can assist in the clinical decision process.

Nutrition algorithms for children, adults, or the elderly can be very useful as automated tools to assess a hospitalized patient for nutritional deficiencies.

Scurvy is a term for clinical deficiency of vitamin C (ascorbic acid). Although encountered less often today than in the past, it still occurs (as we see by the New York Times case) and many cases may go unrecognized.

  • Clinical features of scurvy (vitamin C deficiency)Clinical features of scurvy (vitamin C deficiency)
  • Vitamin C deficiency in a patient with cancerVitamin C deficiency in a patient with cancer

When evaluating patients, the ability to easily consult medical algorithms as part of the clinical decision process aids in prompt evaluation and treatment. Whether straightforward conditions or difficult to diagnose cases such as those referenced in the New York Times Think Like a Doctor series, the Medical Algorithms Company’s platform provides a valuable resource to clinicians.