Wednesday, May 16, 2012

When It Doesn't Make Sense

As doctors in training, we learn to think in patterns of symptoms and can often use "clinical judgement" to fit a patient's presenting symptoms into a diagnosis.  This generally works well, until we are presented with an unfamiliar pattern.  For example, in the early 80's I saw a 60 year old shoe salesman with fatigue and a low grade fever.  He had general malaise and some muscle weakness.  His exam and initial blood work was unrevealing except he was mildly anemic and his sed rate was elevated.  A search for cancer and infection unrevealing.  So my next thought was polymyalgia rheumatica, an autoimmune illness associated with inflammation of medium sized arteries.  I sent him to a surgeon for a temporal artery biopsy which was negative.

About this time he started to get a cough and the chest X-Ray showed a hazy pattern of change.  I knew the symptoms yet had not yet encountered HIV.  He was one of the first cases in our State, but likely we had all missed the boat with similar patients.  Our pattern thinking generally works clinically, but it isn't a very good way to ferret out a new or unexpected disease.  I never thought to ask the right questions or to have a high index of suspicion.  The patient went on to full blown AIDS and died as most patients did in the early days of the HIV epidemic.  So sad.

In another situation, I saw a young man with onset of shaking chills and fever in my clinic.  I immediately thought of a viral or bacterial infection trying to narrow down the possible causes.  But then the patient made the diagnosis for me, "Hey doc, you know I felt just like this when I had malaria in Vietnam."  It was exciting to see his blood smear with parasites in the red blood cells when I went to the lab, but I certainly again felt humbled when thinking about the patterns and short cuts that we tend to use in day to day medicine.

Some of the best primary care physicians I know seem to have a sixth sense when the patient's story and exam just don't seem to add up.  One GP friend called me, "Jim, my patient was diagnosed with pneumonia in Europe but is home now and I don't think she should be this short of breath."  It turned out the patient had survived a major pulmonary embolus and still had dangerous clot in her legs.  As a pulmonologist, I immediately was thinking of air travel and pulmonary emboli.  My GP friend wasn't, he just knew that things didn't sound right and he correctly exercised his "high index of suspicion" that he needed to bounce this off a specialist.  Believe me, I always payed attention when he called.

When I was a resident at a VA Hospital, we had a long term patient with a knee joint infection.  He had been there for a month and a staph infection had now turned into an even more difficult pseudomonas infection requiring fairly toxic IV medications plus joint drainage.  As that knee slowly resolved, the other knee joint became septic.  As in the other cases, this just didn't make sense.  My intern sent the patient down for X-Rays and then checked the bedside table.  Sure enough, there was a vial of cloudy infected urine along with syringes and needles the patient was using to self inject his knees.  The rare diagnosis of Munchausen's Syndrome became apparent, a psychiatric disorder where the patient will induce, suffer and endure a variety of medical and surgical illnesses in their abnormal mental state.

I've always found medicine humbling.  There's far more knowledge there than we can absorb, the patients are endlessly varying in their presentations, and there are so many unknowns about the illnesses they have.  We tend to use such terms as "essential, idiopathic, or primary" as if somehow labeling a condition adds to its understanding.  With the further explosion of knowledge in genetics and bioengineering it brings to mind the lesson I first learned in medical school:  "the questions in medicine never change but every few years the answers do."


3 comments:

  1. ...Thank you for sharing your thoughts...The Internet moves to places in other peoples' mentalities of which `we' have little awareness. It is ironic...more accumuated knowledge, more humility with that understanding and more sadness of the human condition.

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  2. Very interesting post. Thanks so much for sharing these stories about clinical judgement. So often as a patient you edit out the missing pieces of the puzzle without even thinking they might be useful, let alone crucial.

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  3. Jim,
    I appreciate your sharing your stories on kevinmd.com and will now follow your blog closely. Over thirty years ago, you were an inspiration to my med school classmates and myself at UW--one of the shining stars among our teachers--and I benefited always from rounds with you and the wisdom you shared. Most of all, you were approachable, and I can tell from the way you write, that has never been lost! Emily Polis Gibson (family doc)

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