Complicating the Obvious or Why a Duck is a Duck by Peter S. Kibbe MD FHM

 A  doctor and a duck walk into a bar and the bartender says that they don’t serve ducks.  So the doctor says, “This isn’t a duck!” and… well, more on this below.

A physician friend of mine recently proved that he understood the saying that a physician who treats himself usually has a fool for a patient.  He showed me a picture of a rash he had developed a few days earlier on his arm.  He explained that he at first attempted to ignore it, then called his personal physician and sent the cell phone image of the rash to him.  My friend thought it was a rash typical of Lyme disease and his physician agreed that of course, it was and could be nothing else and immediately prescribed the proper antibiotic.  My friend was working in the woods around his house, developed the rash, malaise and fever.  Almost no other infection has that typical rash as a sign, none in an Ohioan who has not been traveling to the Southwest of the U.S.  It could be nothing else.

All laboratory tests at this point would be academic.  It is what it is.

Many clinical syndromes present this way, glaringly obvious from the history and physical examination alone, yet we appear, at least in the environments where I practice, to complicate them for our patients.

I would argue, as have many,  that much of the testing, imaging and other diagnostics we order for patients should be seen as a burden we place on them.  This burden can be emotional, engendered by anxiety and fear while awaiting the test results, and as well it can be a physical burden—the radiation delivered with CT scanning, the physical discomfort experienced with certain imaging procedures or the negative consequences of the sedation required for certain procedures.

Being placed in a hospital bed can be a burden as well in terms of financial loss, lost time, disturbed sleep and dietary patterns and, for the elderly, the rapid deconditioning they experience by being made immobile.

Not long ago I was referred a patient for admission for observation who, I was told by the emergency department clinician, had experienced a syncopal episode while standing in her kitchen.  She was a very healthy and active 80-something whom I encountered with her husband.  The history was a bit more complicated but the history alone pin-pointed the cause of her brief faint.

She, for several months, had been experiencing severe pain in the right hip, a joint that had been replaced several years prior.  The pain was not a problem when she was active and did not interfere with her  routine of daily and very long walks.  She got in a couple of miles or more.  She loved to cook and she found that after prolonged standing at her kitchen counter the pain would become disabling.  It was relieved by sitting and when I first encountered her she was pain-free.  On the day of her presentation she was making one of her complex culinary favorites when the pain began and it progressed.  Her husband found her in distress, standing and grimacing, and as he helped her to a chair she briefly lost consciousness without any other sign or symptom, and then very rapidly awakened.  The inevitable CAT scan of her brain was obtained which was negative.  She was fully ambulatory. Her vital signs were normal.  Her hip was not tender.  Her past medical history was, other than bone and joint problems, a blank.  Her electrocardiogram was normal.

So, how could placing this person in a hospital bed tethered to a cardiac monitor be to her benefit?  It could not. Radiating her head would not help either.  She had an orthopedic problem which caused a vasovagal syncope.  Intense pain often causes the blood pressure to drop, cerebral perfusion transiently drops, brief syncope ensues.  My old chief of medicine used to call these “house call” or “black bag” cases, meaning all you need to sort things out is your brain, a stethoscope, a sphygmomanometer, maybe a reflex hammer and light source.

In complicating the simple we often  forget the old saw that “If something looks like a duck, walks like a duck, swims like a duck  and quacks like a duck,  it probably really is a duck.