The Smokey Zebra on the River Congo.

In medical school, and extending through residency, we are trained by repetition. It is an incredibly time consuming job of pattern recognition. It is a process which, as far as I'm concerned, structurally changed my neurons.

A lot of what I do in my daily practice of a hospitalist is automatic. I have seen hundreds of patients with the same diagnosis. The treatment is what we like to "call standard of care" (what ever that means).

As a physician, my job is to figure out when deviation from that standard is warranted. That's where the repetition of my education comes into play.

Do I treat all COPD exacerbations the same?

Do I treat all DVT's the same?

Do I treat all Afib the same?

DO I treat all pneumonia the same?

The answer is no. But the treatments are very similar, and the differences can be very subtle.

From avoiding medications due to other confounding medical conditions.

To adjusting doses for liver or kidney problems.

To using completely different therapies due to advanced or minimal nature of the disease.

To taking into account the age, the functional status and the social and economic issues that play such important roles in determining appropriate therapies.

So, while I may have seen 100's (even 1000's) of cases of afib or stroke or diabetes or pneumonia or coronary syndrome (and on and on), the general treatments are ingrained, but the nuances are oh so important from patient to patient.

This represents the bread and butter of medical care for any physician.

There are 10 or less medical conditions, that for any specific specialty, represents upwards of 80-90% of the practice.

These are the Horses.

The common conditions which you could treat with your eyes closed and both hands tied behind your back.

Part of my training, in 7 long years was not only to learn about the horses (the common conditions, the conditions that cost trillions of dollars), but also the recognize the not so common medical conditions, that will always keeps a physician on guard.

I had one such experience lately. And I remember very clearly, like it was yesterday, those famous words...

"atrial smoke"

Those two words, triggered, and will always trigger in my mind a very specific medical condition. It's one of those things that you never forget. And the work up was triggered by a very astute cardiac echo technologist.

This is the zebra in a world of horses. The common presentation of an uncommon problem.

How did my patient present?

Hemoptysis and shortness of breath.

Well, we could have left it at that, considering the patient also tested positive for the flu.

It would be a reasonable assumption. Acute inflammatory reaction from Influenza, associated with hemoptysis.

But that would have been wrong.

My 60's female, as part of the work up also had a screening EKG. On this EKG were changes of LVH (left ventricular hypertrophy). On exam was a murmur as well.

Now, generally, hemoptysis, that's considered a primary lung issue. Pulmonary embolism, pneumonia. Not normally a primary cardiac problem.

On admission, the pulmonologist was consulted. The CT angiogram was negative for pulmonary embolism. There were no infiltrates.

The question remained.

Why?

Why coughing up blood?

Well, the assumption was, after the influenza screen came back positive, the assumption was influenza. But that, in my mind was a very soft assumption.

The plan was to bronch. Take a peak in the lung and look around. Look for tumor. Look for anything bleeding. AVM, irritation. What ever.

But that EKG bothered my. Why the LVH, and the murmur, with the shortness of breath?

Were we breaking the rules of internal medicine? Did we have two independent and separate new diagnosis'?

I ordered an echo. Maybe she had aortic stenosis I thought. The murmur was impressive and the EKG was equally impressive.

The echo returned. It didn't really matter to me what the final report said. I remember getting a call from the echo tech.

"Smoke in the atria", consider.....

I knew right then, bingo, we may have a unifying diagnosis. The echo tech was on their game. I knew exactly what they were talking about. I could picture the words as clear as a Hawaiin stream.

Amyloidosis.

Smoke in the atria=amyloid.

This was a zebra.

Who the hell gets amyloid?

Well, by now, the cardiologists are involved. They recommended a fat pad biopsy. Well, it had been years since the cardiologist was an internist, and I suggested rather that we go for a rectal biopsy. According to our pathologist, this was more likely to yield a positive result.

So know, we get the gastroenterologist involved. My request is fulfilled.

Bronchoscopy negative (not surprising)

Rectal biopsy by flex sig, positive for amyloid by Congo Red Stain.

Congo Red. Another key word that sticks in my neurons till the end of time.

Congo Red = Amyloid.

Here was a full blown Zebra.

A diagnosis of amyloidosis in a 60's female who comes in during the height of the flu season coughing up blood and testing positive for the flu.

It took years and years and years and years to learn not only how to treat every patient differently, even with extremely common (and sometimes boring) medical problems, but also to always be on the look out for those zebras.

This is the 7-10 years of education required to make these kinds of diagnosis.

These are physicians. Not providers. Not extenders.

Physicians.

It's times like this that separate doctors from everybody else in the health care field.

Would this patient have achieved her diagnosis if she was admitted under a pulmonologist?

Maybe. Maybe not.

Would this patient have achieved her diagnosis if she was admitted under another internist?

Maybe. Maybe not.

I do know, that everything played out perfectly for her, due to the team effort and doctors on their game that day, including, I must say.

Me.

It's a good feeling to give a patient the answer. Whether that answer is good news or bad news.

An answer, often times, is what matters most

A diagnosis was made and her life could go on.

photo credit