One Case, One More Lesson

One case, more than one lesson.  The multifactorial nature of causation in a story.

The 50ish woman came in for a complete physical with nearly every symptom on the review of symptoms checked off.  We call that a “positive review of systems,” and it usually points to mental stress of some kind, not to organic disease.  But.  Just to be safe.

Her exam was completely normal, but over time, I had grown from the young doc who thinks the old timers just order too many tests into the middle timer who once in a while found something important with “routine lab work.”  I had found hyperthyroidism, hypothyroidism (quite commonly), hyperparathyroidism, early kidney failure, hepatitis, anemia, and more, just by ordering a complete blood count, chemistry panel and a TSH routinely.  So I ordered them.  I had very excellent lab techs.  They always looked at the blood under the microscope with every complete blood count.  The tech in 5 minutes came to me and announced, “Your patient has hairy cell leukemia!”  Well, I had heard of it in training, never run across a case.  I looked at the cells under the microscope and understood that this was not a hard call, just a rare disease.  Those white cells really did look hairy!  Lesson one:  trust your lab tech!  Lesson two:  even the stressed out can have a real disease!!

Of course, I referred her to a hematology/oncology doc.  As nearly always happens, I didn’t see her again!  Once patients get a specialty-managed diagnosis, they almost always disappear, and consequently fail to get their primary care.  Especially cancer patients!  The best specialists send them back, but that’s a small minority.  However, the doc put her leukemia into remission and watched her after that for 5 years, then pronounced her cured and recommended she return to primary care.  Great doc!  Of course, he was independent, and the hospital didn’t like that, couldn’t buy him, so they hired competition for him.  Such is how it goes!

So, she came back in for a complete physical, and her review of systems was almost identical to the first time when she had acute leukemia.  I did her exam, which was normal.  She had already had her blood work done by the oncologist, so no need to repeat and wait for that.  So I told her, “You’re list of symptoms is just about identical to the day we diagnosed your leukemia, but now you’re cured of that.”  ”How can that be?”  “Well, some folks register a lot of symptoms that are not from a major disease, but from stress or something like that.”  “Wow!  And all these years I thought it was my leukemia!”

Lesson 3, what looks common, often IS common.  While lots of times Occam’s razor works (the simplest explanation tends to be right), so in this case, “everything is due to leukemia”, which turned out to be wrong! Sometimes, the multifactorial nature of causation reveals something else:  The answer to most either/or questions is yes or no, both/and/neither.  In her case, I never got to the root of her many symptoms, but at least we cured her leukemia!