Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Diagnosis requires seeing patient problems with a wide lens

Jerome Groopman, MD and Pamela Hartzband, MD
Conditions
June 11, 2010
3 Shares
Share
Tweet
Share

Susan Sorensen, FACP, an internist and hematologist in Palo Alto, Calif., told us of a case where the correct diagnosis took more than a year to make. The patient was a 24-year-old woman who had developed weight loss, fatigue and intermittent chest tightness. She was seen in a local emergency department, and was told that she should consult a pulmonary specialist. A chest X-ray and EKG appeared normal.

Over the next few months, she continued to feel unwell, losing more weight and developing a new symptom, intermittent abdominal pain, predominantly in her left lower quadrant. She was seen again in the emergency department, and received a diagnosis of possible urinary tract infection. A course of antibiotics did not improve her symptoms. She returned to the emergency department during a bout of abdominal pain, and was referred to a gynecologist. A pelvic ultrasound was unremarkable, and she was prescribed a second course of antibiotics for possible pelvic inflammatory disease.

She did not improve after this second empiric regimen of antibiotics, and continued to experience intermittent symptoms of abdominal pain, mostly in the left lower quadrant, with frequent bowel movements but no diarrhea. She lost an additional 10 pounds, and noted early satiety. After another visit to the emergency department, she was referred to a gastroenterologist, who evaluated her for celiac disease and tested her for food allergies; all tests were negative. The gastroenterologist performed an upper endoscopy, which was unremarkable.

Her symptoms persisted and she developed drenching night sweats and excruciating headaches, which prompted another visit to the emergency department. Neurological evaluation, including an MRI scan of the head and an EEG, were negative. She was given the diagnosis of possible abdominal migraine. An endocrine evaluation yielded a normal corticotropin stimulation test. A bout of severe nausea brought her once again to the emergency department and she was treated with ondansetron (Zofran). The emergency department physician noted cervical lymphadenopathy and she was referred for a lymph node aspiration, which yielded only adipose tissue. A workup for a possible occult malignancy, including a CT scan of the chest, abdomen, and pelvis, was negative, although sclerosis of the sacroiliac joints was noted. Lacking a diagnosis, a house officer told her, “You need to eat more.”

An internist steps in

After more than six visits to the emergency department and evaluations by multiple specialists, the patient was referred to Dr. Sorensen.

The first thing the woman said was, “I am afraid I’m wasting your time. I am not having any pain right now.” Dr. Sorensen realized that the patient thought it was only appropriate to seek help for her symptoms when she was having an acute episode. Each time she received care in an emergency department, and then was referred to a different specialist. Her symptoms had now been present for almost a year, and included drenching night sweats, bowel movements after each meal, nausea, anorexia and abdominal pain that was intermittent and most prominent in the left lower quadrant.

On further questioning, she reported left hip stiffness and right knee pain. Her medical history was significant for seronegative juvenile rheumatoid arthritis as a child, which had resolved at puberty. A 17-year-old cousin had recently been diagnosed with Crohn’s disease.

On physical exam, her body mass index was 16.8. There was mild tenderness in the left lower quadrant and, on pelvic examination, tenderness in the left adnexa. Her left sacroiliac joint was quite tender to palpation. Additional laboratory testing included negative antinuclear antibody panel and negative stool cultures. Dr Sorensen reviewed all of the patient’s previous scans and confirmed the presence of sacroiliitis. Her human leukocyte antigen B27 was negative.

Dr. Sorensen suspected a diagnosis of Crohn’s disease, and this was confirmed with lower endoscopy and biopsy of the terminal ileum. The patient was treated with mesalamine with improvement of her symptoms.

Through a lens, narrowly

As we heard this case, we were reminded of the parable of the blind men and the elephant. There are versions of this tale in many cultures, each slightly different, but the most famous one is the Hindi version popularized by John Godfrey Saxe in his poem. A group of blind men touch an elephant to determine what it is like. Each one touches only one part of the elephant, and they then can’t agree. In the case of this young woman, each specialist viewed the patient’s symptoms in the context of his or her own specialty.

Each saw the patient’s problems through a narrow lens, and demonstrated a mix of anchoring and availability. Anchoring is seizing upon the first bit of information that you encounter, analogous to grasping the elephant’s tail or its tusk or its leg. Availability is calling up what is most familiar or dramatic in past encounters, and understandably, specialists think about diagnoses within their own field, because they are most experienced with these disorders and they consider them first. Indeed, as the case unfolded, each of us immediately thought of diagnoses in our own disciplines: malignancy as an oncologist (Dr. Groopman), adrenal insufficiency or hyperthyroidism as an endocrinologist (Dr. Hartzband).

It is particularly the role of the internist to consider the disparate fragments of the patient’s history, examination and evaluation and knit these pieces together to arrive at the correct diagnosis, mindful that each isolated part of the “elephant” must be combined with the others to yield the correct form.

Jerome Groopman, a hematologist-oncologist and endocrinologist, and Pamela Hartzband are staff physicians at Boston’s Beth Israel Deaconess Medical Center. They are authors of Your Medical Mind: How to Decide What Is Right for You. This article was originally published in ACP Internist.

Prev

Wii Sports and Wii Fit Plus exercise equivalents

June 11, 2010 Kevin 0
…
Next

AMA: Senate fails to stop a Medicare meltdown

June 11, 2010 Kevin 10
…

Tagged as: Primary Care

Post navigation

< Previous Post
Wii Sports and Wii Fit Plus exercise equivalents
Next Post >
AMA: Senate fails to stop a Medicare meltdown

More by Jerome Groopman, MD and Pamela Hartzband, MD

  • a desk with keyboard and ipad with the kevinmd logo

    A doctor is humbled about chronic pain

    Jerome Groopman, MD and Pamela Hartzband, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Physicians gain unique insights when they become ill themselves

    Jerome Groopman, MD and Pamela Hartzband, MD
  • a desk with keyboard and ipad with the kevinmd logo

    I teach the anchoring error, but I couldn’t avoid it myself

    Jerome Groopman, MD and Pamela Hartzband, MD

More in Conditions

  • From hope to heartbreak: a story of loss in the ICU

    Ton La, Jr., MD, JD
  • The beauty of a patient’s gratitude

    Dr. Damane Zehra
  • From clocking in to clocking out: the transition to retirement

    Debbie Moore-Black, RN
  • Overcoming Parkinson’s: a journey of laughter and resilience

    Cynthia Poire Mathews, FNP
  • The untold struggles patients face with resident doctors

    Denise Reich
  • Maximize sleep efficiency with stimulus control

    Pedram Navab, DO
  • Most Popular

  • Past Week

    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Physicians are a finite resource we need to protect

      Jack Resneck, Jr., MD | Physician
    • From clocking in to clocking out: the transition to retirement

      Debbie Moore-Black, RN | Conditions
    • From hope to heartbreak: a story of loss in the ICU

      Ton La, Jr., MD, JD | Conditions
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
  • Recent Posts

    • From hope to heartbreak: a story of loss in the ICU

      Ton La, Jr., MD, JD | Conditions
    • Unlearning our habits: a journey from intelligence to wisdom

      Brian Sayers, MD | Physician
    • Lessons from an orthopedic surgery journey [PODCAST]

      The Podcast by KevinMD | Podcast
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Maximizing physician potential: How coaching can aid in conflict resolution, enhance health care leadership and build stronger teams

      Asha Padmanabhan, MD | Physician
    • The future of education: AI empowerment, YouTube college credits, and the impact on traditional colleges

      Harvey Castro, MD, MBA | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 8 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Why I Don't Identify With Women's History Month as a Black Doctor
  • A Drink or Two a Day Won't Help Prolong Life
  • Sleep, Exercise, and Death; Pope Improving, Eats Pizza; Obesity Med Strategies
  • U.S. Study Backs 'Helper' Virus Theory in Kids' Mystery Hepatitis Cases
  • Moderna's Steep COVID Vaccine Price: Corporate Greed or Capitalism?

Meeting Coverage

  • VTE Risk in Recurrent Ovarian Cancer Increases With More Lines of Chemotherapy
  • Obesity's Impact on Uterine Cancer Risk Greater in Younger Age Groups
  • Oral Roflumilast Effective in the Treatment of Plaque Psoriasis
  • Phase III Trials 'Hit a Home Run' in Advanced Endometrial Cancer
  • Cannabis Use Common in Post-Surgery Patients on Opioid Tapering
  • Most Popular

  • Past Week

    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Physicians are a finite resource we need to protect

      Jack Resneck, Jr., MD | Physician
    • From clocking in to clocking out: the transition to retirement

      Debbie Moore-Black, RN | Conditions
    • From hope to heartbreak: a story of loss in the ICU

      Ton La, Jr., MD, JD | Conditions
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
  • Recent Posts

    • From hope to heartbreak: a story of loss in the ICU

      Ton La, Jr., MD, JD | Conditions
    • Unlearning our habits: a journey from intelligence to wisdom

      Brian Sayers, MD | Physician
    • Lessons from an orthopedic surgery journey [PODCAST]

      The Podcast by KevinMD | Podcast
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Maximizing physician potential: How coaching can aid in conflict resolution, enhance health care leadership and build stronger teams

      Asha Padmanabhan, MD | Physician
    • The future of education: AI empowerment, YouTube college credits, and the impact on traditional colleges

      Harvey Castro, MD, MBA | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Diagnosis requires seeing patient problems with a wide lens
8 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...