Snap Diagnosis

At the nursing home the other day I saw a young man in blue scrubs push a laundry cart up the hall. He must be new, I thought, trying to catch a glimpse of his name tag. As he approached the nurse’s desk he made a sudden noise.

“Bless you”, one of the nurses said.

The young man smiled briefly. “I didn’t sneeze, but thank you. I am probably the most blessed person around.”

I wasn’t sure what that little exchange was all about and continued reading the hospital discharge summary of my new admission. In the periphery of my visual field I saw the young man starting to sort through the items on his cart.

Suddenly he made the same unusual sound, kinked his head and snorted twice again before picking up a pile of clean towels.

Tourette’s syndrome, I thought to myself. Naturally, people must mistake his verbal tics for sneezes all the time and say “Bless you”.

I remembered the day I made that diagnosis for the first time.

It was a bitterly cold Tuesday morning in early December. I was doing a rural rotation six months into my residency, back in my hometown in Sweden. One of my assignments was to hold a weekly clinic for the inmates at a remote prison in a wind-battered coastal town twenty miles from our hospital.

Five miles into my commute the heater in my second-hand Volvo wagon was still blowing cold air, and the base model didn’t come with heated seats. Shivering, I turned the radio on for some distraction from the cold. Just then, the announcer came on the air and said that John Lennon had been shot.

I drove the remaining fifteen miles in a daze, unaware of the temperature or the scenery. I walked up the stairs to the prison clinic and settled into the sparse consultation room. Through the surprisingly thin walls I could hear the clinic nurse escort my first patient of the morning down the hall and into the adjoining exam room.

My daily schedule listed each patient’s name, birth date and chief complaint. As I glanced down the list I heard strange sounds coming from the exam room. By now the inmate was alone in the room – the nurse’s clogs had echoed down the corridor moments before.

Through the wall to my right I heard muttering and a series of coughs and snorts, each punctuated by a sudden, unintelligible monosyllabic outburst.

I began to worry. I was about to enter the room with this individual, and I didn’t know how safe that might be. Was this a violent, uncontrollable person I was hearing, tormented by horrific hallucinations and delusions, likely to snap at any moment? I looked at the patient roster, where his chief complaint was listed as “tics”, which I knew very little about.

I looked around the office. There were only two books on the blond government issue office desk – a Swedish drug reference and the Merck manual, in English.

I searched the index of the Merck Manual and hurried to the section about tics. There, I quickly found exactly what I was hearing through the wall to my right: Gilles de la Tourette Syndrome. I vaguely remembered hearing something about it in medical school, but I had never seen a case of it, and in 1980 there wasn’t the public awareness of this condition that there is today.

Armed with my newly found knowledge about the condition and its treatment, I entered the room, facing only my fear of getting hurt.

The young man seemed gentle and soft-spoken. He greeted me politely and I introduced myself. He told me he had these tics that nobody seemed able to help him with. Suddenly he snorted, kinked his neck and swore under his breath.

“I know what you’ve got”, I said. “I think I can help you.”

“Really?” he said and smiled with tears in his eyes.

1 Response to “Snap Diagnosis”

  1. 1 DocJock February 10, 2010 at 1:11 pm

    The Merck Manual, what a great boon to us physicians! Cheap and as up to date as possible in a textbook. I used it first when I worked in Canada, and still use it here in the UK, where many doctors haven’t heard of it.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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