Looking for Patterns, Looking for Change and Looking for Incongruity

I recently reposted a 2017 WordPress reflection on my Substack about how sometimes a disease evolves so slowly that you, as a continuity provider, barely notice it but another, covering, provider notices the subtle abnormalities and recognizes the pattern as a new disease.

When taking a medical history, it is often very difficult to pin down the duration of a patient’s symptoms or the speed of change. For example, patients tell me all the time that they had muscle aches on a statin drug. When I then ask if they never had them before they started that drug or if they never had them after they stopped it, I often don’t get a straight answer. And when people report alarming symptoms without mentioning that they’ve had them for decades, you could easily fall into the trap of overreacting to chronic symptoms.

The art of diagnosis is said to be 80% the art of taking a good history of the clinical symptoms. Doing an appropriate, skillful exam is probably a disappearing or at least undervalued skill. Knowing what test to order if you suspect something, and sometimes even if you have a handle on the most prominent symptom, is something your computer can help you with, from UpToDate to DxGPT.

Then there is the many facets of incongruity. Just the other day, I saw an older woman with years of gastrointestinal problems. She knew she was lactose intolerant, but when my assistant walked into her kitchen where she kept her testing equipment for her home INR blood testing for her warfarin anticoagulation, she noticed a table full of 1% milk cartons. When we pointed out that she seems to be drinking milk even though she is lactose intolerant, she responded, “but it’s only 1%”. “Yes only 1% fat, but still a lot of lactose”, I told her. “Oh, I had no idea”, was her answer. Incongruity can be an issue of what’s around in the home, how a person talks or moves when they are distracted from describing how ill they feel, and many more things.

I used to like old mysteries when I was younger. I watched Columbo and Perry Mason. I don’t watch mysteries anymore. I get enough of that in my work…