Always Looking for Zebras

In everyday clinical practice, we see mostly ordinary things. But our job description requires us to always at least consider the unusual. It takes judgement and experience to navigate between being efficient and not missing something rare or dangerous.

This past week, I have seen a couple of patients that made me dig a little deeper into their symptoms.

One man came in with a six month history of skin rashes. He seemed to have several kinds. Some were isolated little papules on a red background. He said he had had that kind now and then for many years. Some were scaly blotches with bumpy edges and some were red patches with little craters within them.

A few of the lesions reminded me of dermatitis herpetiformis, so I asked “have you had any trouble with your bowels lately?”

“Well, yes, they’ve been real loose.” He seemed surprised by my question.

“How many times a day?” I asked.

“At least three or four”, he answered.

I minimized the EMR and googled images of dermatitis herpetiformis, which is usually seen with celiac disease, but sometimes without full blown bowel disease. He agreed that some of the pictures looked a bit familiar. I ordered a celiac panel. If that is negative, I’ll do a skin biopsy, but none of the lesions I saw were quite classic, so maybe I’ll do a couple of them.

Another patient with longstanding anxiety disorder had a very elevated blood pressure, which I had never seen in her before. She told me she has seen numbers from 120 to 180.

“Why have you been checking your blood pressure to begin with?” I asked.

“Because I break into a sweat and feel dizzy sometimes”, she explained.

Here we go again, I thought to myself. Another instance to look for a pheochromocytoma. Most of the time when we look for this rare cause of spells with high blood pressure, we don’t find it, but you have to look.

We must be careful not to zero in too quickly on the presenting complaint. That is like wearing blinders, like the horses pulling the Amish buggies down the road from me. But at the same time we can’t scan the horizon so much that we become scattered and paranoid.

The Art of Asking: What Else is Going on?

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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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