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Seeing the whole picture

From the April ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Jerome Groopman, FACP, and Pamela Hartzband, FACP

Sidebar: The Blindmen and the Elephant

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.

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Photo by Photodisc/Illustration by Lorraine Lostracco

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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 her prior 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 other to yield the correct form.

Jerome Groopman, FACP, a hematologist/oncologist and author of the bestselling “How Doctors Think,” and endocrinologist Pamela Hartzband, FACP, are on the Harvard Medical School faculty. They also serve as staff physicians at Beth Israel Deaconess Medical Center, where Dr. Hartzband co-directs the internal medicine subinternship program.

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The Blindmen and the Elephant

By John Godfrey Saxe, FACP

It was six men of Hindustan

To learning much inclined,

Who went to see the Elephant

(Though all of them were blind)

That each by observation

Might satisfy the mind.

The first approached the Elephant

And happening to fall

Against his broad and sturdy side

At once began to bawl

“Bless me, it seems the Elephant

Is very like a wall.”

The second, feeling of his tusk,

Cried, “Ho! What have we here

So very round and smooth and sharp?

To me ‘tis mighty clear

This wonder of an Elephant

Is very like a spear.”

The third approached the animal,

And happening to take

The squirming trunk within his hands,

Then boldly up and spake

“I see,” quoth he, “the Elephant

Is very like a snake.”

The Fourth reached out an eager hand,

And felt about the knee.

“What most this wondrous beast is like

Is mighty plain,” quoth he;

“‘Tis clear enough the Elephant

Is very like a tree!”

The Fifth, who chanced to touch the ear,

Said: “E’en the blindest man

Can tell what this resembles most;

Deny the fact who can,

This marvel of an Elephant

Is very like a fan!”

The Sixth no sooner had begun

About the beast to grope,

Than, seizing on the swinging tail

That fell within his scope,

“I see,” quoth he, “the Elephant

Is very like a rope!”

And so these men of Hindustan

Disputed loud and long,

Each in his own opinion

Exceeding stiff and strong,

Though each was partly in the right

And all were in the wrong.

(Abridged from Wikisource)

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated