Q: I am 25 years old male suffering from joint pain for the last two years. First, it started with back pain and then I started having needle-like pain in my heels. Now I am having inflammation in the feet and hips along with stiffness in the knee. I have consulted many orthopaedic surgeons. Some asked me to exercise but it didn't really help. My RA is negative and recent blood report shows uric acid as 9.9. One of the doctors says that I have gout. But I never ever had any swelling. I am confused. I want the perfect diagnosis and want to know the exact disease I am suffering from.

A:Your age is only 25 years, not the usual age group for rheumatoid arthritis or for that matter even for gout. Again, gout does not usually present with back pain. It may present with ankle foot swelling and pain. But it is unusual to present with backache. You have asked for a perfect diagnosis. There is nothing like a perfect diagnosis. A clinical diagnosis is arrived at based on a combination of patient’s history, the physical findings as seen by a physician at the time of examination and a correlation of this with the investigations that are done. These investigations could include blood biochemistries, X-ray, MRI, or any other imaging modality used. Please remember nothing is viewed in isolation. Every aspect of history, physical examination and investigation must ‘gel in’ to a common diagnosis before the doctor gives his or her opinion. By and large medical training is designed in such a way that if one disease can explain all the symptoms and a signs of the patient then that disease is kept as the most probable diagnosis. Unless there are very specific reasons to believe that there are other concurrent illnesses we tend to look at one diagnosis to explain all the problems of the patient. The problem with this approach is that there is a small possibility of under or over diagnosis. In addition, we are looking at the patient at one point in time and correlate past and present events and findings with a possible diagnosis. Sometimes a sequential examination is essential to have a clear picture of the problems. At times when the patient has been to two or three doctors and a doctor then reevaluates the entire history the diagnosis may look very obvious and simple and the patient may wonder why his doctor missed the obvious diagnosis. Doctors often use shortcuts based on some rules of thumb for different diagnosis. These are referred to heuristics. If a disease has a few of the typical signs and symptoms the doctor is likely to think as representative case of a particular diagnosis (representative heuristics) or the doctor may from his experience remember all the cases that he has seen in his experience with common signs and symptoms which turned out to be a particular diagnosis. If the current case fits in with those of his experience that is available to him it is ‘availability heuristics’. Lastly, the doctor may anchor to a particular feature of the disease and build his diagnosis around that feature (it is called anchoring heuristics) – (Decision making in clinical medicine - Harrisons Principles of Internal Medicine). You may wonder this has no relevance to your case. But I thought I will explain this to help you understand the dynamics of a diagnosis process. It may be simple at times but can be quite complex. Coming back to your case, you need to be reviewed by a good internal physician or by a rheumatologist. It is not necessary that your symptoms be because of high Uric Acid. However, it is also possible that it is so. Someone needs to look at your entire case de novo. This could be an internal physician or a good rheumatologist or even orthopaedic surgeon commonly dealing with arthritis problems. With the history of your backache I would still think it could be a case of inflammatory backache, therefore, please have your case reviewed.