Looking for the Zebras

When I started third year of medical school, I was a zebra whisperer. I think it’s the result of studying so much for Step 1, and reading First Aid trying to memorize the rare diseases. Oh, she has slightly low platelet count and elevated creatinine, we must think about TTP. When in fact AKI was enough to explain her clinical presentation. However, this mentality of painstakingly turning over every stone has helped me in one very memorable instance…

A zebra ^_^

A manic patient from the psych floor in her 40s was transferred to my inpatient internal med unit when I was doing medicine rotation. She (fortuitously you may say) fell on my lap as one of 4 patients I am responsible of following. She experienced syncope and was found to have bradycardia thereafter. She also complained of persistent pain in her left foot. Her HR was normalized by atropine and bedrest, but her foot pain was unabated. My team thought she was malingering because the beds in the psych wards were infamously uncomfortable, but I was unconvinced. I performed the Ottawa Foot rule on her and she was positive at two spots and in addition she was unable to bear weight. I asked for a foot Xray and it was granted. To my dismay, it came back negative. Still skeptical, I meticulously looked at the images myself. I was able to locate a cortical discontinuity on head of first metatarsal on the oblique view. I ran it down to the radiologist’s office for a curbside consult (my favorite type of consult), and he blamed this oversight on his wife’s mistake of making decaf that morning. A noncontrast CT revealed nondisplaced fracture on the first, second and third metatarsal head, and ortho came back and put her in a walking boot the next day.

To the exhilaration of my team, they put this encounter in my final evaluation at the end of my clerkship. Frankly, it was just the way she grimaced and flinched in pain that made me go above and beyond to find the cause. You may say what’s most common is a simple sprain or malingering, but I didn’t want to stop there given how she presented to me. I also think in this case being a psych patient did not help her problem. It’s definitely ideal keep the prejudice out of patient care, and base decision on clinical presentation and patient’s well-being. I am getting better at focusing what’s common these days, but still keeping the zebras in a glass cage so it can be viewed when needed.

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