It’s not lupus

Like many of my peers currently in the medical field, I’ve watched just about every episode of House. The show was incredibly popular for it’s exploration into the human psyche on the background of a weekly medical case. Every week, some patient would come with something unexplained; then, through the episode, House and team would talk about a bunch of stuff, test a bunch of stuff, then solve the puzzle through some fortuitous tangential conversation. This formula became so repetitive that memes arose making fun of it. However repetitive, this sequence of events was one reason many people wanted to do medicine after watching the show and how most of the lay public thinks medicine works; but more often than not, it is much more complicated and not as reassuring.

I started my pediatrics rotation last week on the inpatient service, that is, seeing patients admitted to the hospital. Unbeknownst to me, I volunteered to pick up what turned out to be the most complicated patient on the floor. The patient had been on the service for two weeks with a working diagnosis of fever of unknown origin. Yes this is an actual diagnosis with a formal definition and differentiation from a similar diagnosis- fever without source. I started the service a little over a week into this patient’s stay and had to read up on all of their complicated past medical history and the even more complex workup that had been done over the past week. Up to this point in third year, I’ve only seen patients who have had real diagnoses. Seeing textbook cases materialize in real life patients has been rewarding; having this patient was not the case and a bit frustrating from a purely academic point of view.

Fever of unknown origin has 3 main potential causes: infection, autoimmune, and cancer. On my first day of seeing this patient she already had tests to evaluate all three of those causes and every test came back negative for potential causes of the fever. Usually, treatment goes hand in hand with the diagnosis. Infection? Antibiotics. Autoimmune? Immunosuppressants. Cancer? Chemo/radiation/surgery. So what happens when there is no real diagnosis? Symptom control and lots of retracing your steps to see if you’ve missed something. Over the course of the week, the patient improved with antibiotics and anti nausea medication. We never figured out what it was or if the treatment actually helped or if they just got better on their own.

This was the first case without a real diagnosis I had been assigned to, but it happens all the time in higher levels of medicine, especially in the primary care setting. Patient comes in, test are done, nothing is conclusive, treatments are attempted, and, unlike House, no diagnosis is ever made and the problem generally just goes away, though on rare occasions can get worse. Generally not satisfying for anyone involved with these cases.

In medical school, we spend a lot of time reading textbooks telling us how certain diseases present, how to look for them, and what to do. Very cut and dry. Unfortunately, as doctors often like to say, patients don’t read the textbook. One of the main things I’ve learned so far this year on the wards and was especially apparent with this patient, is that knowing how to think is just as vital as knowing the textbook information. Medicine is a very complex field and I think what separates good doctors from better ones is how they approach a problem and how they handle the unknown.

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