July 27, 2010

Mystery Diagnosis--The Streak


Sometimes it’s easy to figure our why parents call when they do.  If a child is sick, most parents have no problem recognizing this.  Most people are empathic enough to sense when a person has difficulty breathing, or is in pain or distress of some sort.

Sometimes, this is a language problem.  It’s probably not a great idea to speak loudly about a movie that bombed at the box office while going through airport security.  And it always gets my attention when parents tell me that their baby had a hard time breathing last night.  True, a complaint like this is one that will usually get a doctor’s attention.  But if you take advantage of this too often, the doctor could decide you are just crying wolf, and gradually take your complaints less seriously.  

Today, a nice couple came in to the office with their baby.  They had been up all night and said that the baby was having trouble breathing.  I sat up.  Maybe I didn’t really sit up, but instead slouched a little less than I usually do.  After several minutes of interrogation-like questioning, it was clear what the baby’s real problem was.  He was having trouble breathing…through his nose.  This can be a real nuisance for a nursing baby, since they can’t really nurse and breathe at the same time with a stuffy nose.  Still, from the doctor’s point of view, it’s a long and reassuring distance from having trouble breathing.

There are also parents who are generally less anxious.  I try and fail to contain my surprise when a child is brought to me with severe symptoms that have been going on for a long time.  Every doctor has cases like this, some tragic.  For pediatricians, a typical example would be asthma.  Several times a year a child comes in whose parents say that she’s coughing.  For how long, I ask.  ‘Maybe a year,’ they say.

I don’t fault these people.  If the kid was really in trouble, they would have sought help right away.  For some, coming to the doctor is a logistic nightmare consisting of taking time off from work, getting the kid transported, parking expenses, and lots of other incidentals.  (As an aside, it’s easier if the kids actually like going to the doctor.)  Besides the general pain-in-the-neck quality to doctor visits, there’s a natural inclination—often correct—to believe that medical problems that aren’t too bad will probably get better on their own.  Even though I am often sent unusual and difficult cases, many times I have to tell parents that I don’t know what is causing the symptoms they report.  

This brings up an extremely important but subtle part of good medical education and experience.  Some people believe the smartest doctors can diagnose the most exotic problems.  That’s certainly a great and useful skill.  But in primary care practice, especially pediatrics (and, I suspect, geriatrics) where the patients often can’t answer your questions, it’s often most important just to be able to tell worrisome or not.  So though I didn’t know exactly why the baby was congested, I had no idea why the baby was fussy last night, and I didn’t know if the fussiness would happen again tonight, I was confident that the baby was generally OK and would continue to thrive despite having a stuffy nose.

This ability to assess some kind of worry-worthiness grading system seems to be in all of us.  Obviously, some are more anxious than others, and they will grade a threat-level higher than others.  

So it’s not bad parenting that led to the call I got about 4:30 this afternoon.  A mom called and said that her daughter, 6, had a rash.  How long had the rash been there?  At least a month.  I asked more questions, and they decided to come to the office and let me take a look at it immediately, which I did tonight.2010-7-20 lichen striatus-Kayla vertArrows  

Memory is a funny thing.  Sometimes a visual image will stick out like a stone in your shoe.  It’s pretty common for people to say that they know they’ve seen something before, but have trouble placing just when or where.  And I wish I knew why people can look so familiar but I just can’t come up with a name.  This happens to me locally all the time.  Someone will stop me in the supermarket, for example, and say, “Hi Dr. Wolffe.”  I return the greeting but don’t even recognize the person.  Then from another aisle comes grandma with the kids, and I’ll know exactly who they are.  I’m so focused on the children when they are here in the office that sometimes the adults look familiar, but without the kids they are sometimes hard to recall.

The mother said that this girl hadn’t been sick, and this developed over some period of time—she wasn’t really sure how long.  Maybe it was a week, maybe several weeks.  The girl said that it was itchy, but it hadn’t been scratched and she wasn’t scratching it in the office.  It was a little flaky, possibly a little red.  It didn’t hurt.  It had been there for at least a month.  It did feel a tiny bit raised, dry.  Mostly, though, the impression I got was that it was lighter than the surrounding skin and wound like the Andes from her upper arm to her wrist.

The first level of diagnosis, for me, is figuring out if I have to worry about it.  She had it for a month, for goodness sake, and the kid was none the worse.  She was happy and playful in my office.  I looked the kid over, and she was fine.  It’s certainly true that there are diseases that appear to get better and then return.  But most of the bad things generally just get worse, or at least don’t get better.  

The next question for me is if I know what this is.  I didn’t know.  But I knew I had seen it before.  But where?  What was it called?  I think that I am a reasonable diagnostician because I have real difficulty putting this aside and catching up with all the work I really have to do.  I eliminated the rashes that cause light streaks on the skin, but are there since birth.  I crossed off the ones that hurt or itch a lot or come from trauma of some kind.  And the ones that are very smooth or very rough or whorled like a cowlick.  So the diagnosis gradually came to me, but I hadn’t seen it in so long that I couldn’t be sure.  I excused myself from the exam room, and went to the computer in my little office.  It wasn't helpful.  I went to a reference textbook.  I looked up what it was…and I had been, well, close.  This was Lichen Striatus, a bizarre thing that preferentially appears in girls (no one knows why), of age 3-6 or so (no one knows why), usually affects a single extremity (no one knows why), and goes away by itself after some weeks to months (no one knows why).  No one knows what causes it.  It doesn’t seem to do any permanent damage, and generally needs no treatment.

(This is a good example, however, of the incremental information value of an analog book.  I was thinking right, and knew what kind of rash it was.  My first guess was indeed Lichen Striatus, but I couldn’t remember the right name.  I kept thinking, ‘Lichen…something.’  Honestly, I confabulated a last name for this disease.  I looked in the index for ‘Lichen Linearis.’  Seriously.  There is no such condition, and perhaps if my Latin training had been a little more thorough—or I had paid better attention—I would have realized this.  I had unintentionally taken a word from a real but unrelated problem called Lichen Planus Linearis (which I didn’t think this was), and stuck it in the empty spot, like a medical MadLibs game for doctor geeks.  I looked it up on the computer—but could not find the misnamed disease.  It was only when I went to the textbook and leafed through the index section starting with the word Lichen that a bell really rang for me.  Then when I saw the textbook pictures, I knew I was right.  This is the difference between going to the library to find a book on the shelf and getting the book, fully scanned, online.  Sometimes what is most valuable isn’t what you’re looking for, it’s what’s next to what you’re looking for.)

I forgot to ask the mom why, today, she called to have the child seen.  I’d be interested.

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