A patient appointment for a physical could yield a cancer suspicion or diagnosis. An appointment for chest pain could lead to an intervention for domestic violence. A quick visit for a skin rash could land a high school senior in the hospital for a leukemia workup.
In this business we can never assume that a visit will be about what we somewhat callously have been calling the “Chief Complaint”. You have to be prepared to shift gears, sometimes because the patient drops a hint or a bombshell revelation they didn’t tell the scheduler, front staff or medical assistant. And sometimes because you hear, see or palpate something suspicious.
In some ways, we always have to be triaging, before we settle into a “routine” visit. Triage comes from the French word “trier”, which means “to sort” or “to select”.
Primary care is messy. We have to sort who needs something done quickly for a high risk symptom or finding, who needs a different level of care, who needs simple reassurance and who needs a long term plan.
All of this without forgetting the screening and preventive health agendas, which is what we are graded on. There is no formal tool to evaluate our diagnostic acumen. So we are measured for what is easy to measure, the so called “street light effect”.
An Innocent Looking Rash
The Art of Listening: Beyond the Chief Complaint
Primary Care is Messy
A Country Doctor Writes: 
It is much easier to make measurements than to know exactly what we are measuring.
JWN Sullivan, Physicist c. 1920’s
A memorable encounter in response to your essay “An Innocent Looking Rash” happened during my pediatric residency. A father brought his young adult son with Down Syndrome to the pediatric ER to have us look at his swollen knee. Not only was the knee warm, painful, and had a large effusion, but the young man had a fever and looked very pale. Sometimes you know it’s more than the chief complaint. His blood work showed acute leukemia and he was admitted immediately. It was a lot for the dad to take in, and he had not known that his son had a higher risk of ALL than the general population. He had a hard time believing the news about the leukemia and kept asking, “But what about his knee?” We were just glad he had been brought in. I think an orthopedic surgeon drained his knee effusion the next day with a needle and it contained malignant cells as well.