When It Doesn’t Make Sense

May 16, 2012

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 [...] continue the story