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‘Doc, I have this inexplicable symptom…’

Dr Zoe Norris

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I think I’m not a bad GP. I am pretty good at listening. I’m also fairly honest with my patients when I need to google things – I’ll happily admit I can’t remember the latest advice on changing from mirtazapine to citalopram, and that I’d rather double-check, and they tend to accept that.

So if I’m willing to confess that I don’t know things, or can’t remember the names of particular drugs, why am I so uncomfortable about doing the same with certain symptoms? You know the type of presentation:

‘There’s this spot the size of a 50 pence piece on my right arm that tingles for five seconds every three weeks – what do you think is wrong doc?’

Our internal differential machine starts up. Which arm? If it’s left must rule out angina. When they say arm do they mean shoulder or hand, could it be neck related?

The platitudes peter out but the patient is still hanging on my every word

‘It’s on my right arm.’

(Phew – probably not heart.)

‘Lasts for a few seconds at a time.’

(Maybe MSK?)

‘Tingling.’

(Maybe nerve related?)

‘And is in the shape of a 50p coin just here.’

(Don’t think there’s a nerve that supplies that exact spot… is there?)

‘And it happens every three weeks.’

(Erm …?!)

Presentations like this floor me. I cycle through the key differentials, trying to make a weird symptom fit into a nice neat box. I proceed to a full systems enquiry in the hope of being given a clue. Nothing.

Next comes a detailed examination of the affected area (with consent, chaperone offered and declined), trying to cover the range of weird neurological testing we learned at medical school to pad things out a bit. Throw in a bit of joint examination, and some sage nodding. But the moment of truth can only be put off for so long, with the patient looking at me, anticipating the verdict.

I have literally no idea what this is.

I look back at the notes, hoping the computer will show me a previously missed entry from a clever colleague who saw the patient with the same thing and delivered a stunning diagnosis. Computer says no. I take a deep breath and turn to face the patient.

‘Well, the main thing is that I don’t think this is anything serious. I’ve had a good look at the area, and I can’t see anything wrong. I’ve checked the bones and muscles, the nerves and your coordination – it all looks fine. It’s also reassuring that this only seems to happen every three weeks and in such a specific place…’

The platitudes peter out but the patient is still hanging on my every word, waiting eagerly for the punchline. Should I explain it’s a sign of early ringworm and give them some Daktarin? Won’t do any harm but will buy me some time. Then inspiration finally strikes.

‘So I suggest we watch and wait. These things often settle down with time. If it doesn’t, I do recommend my colleague Dr Copperfield. He has a particular interest in these presentations and I’m sure would be very happy to see you.’

#nailedit

Dr Zoe Norris is a GP in Hull  

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Readers' comments (7)

  • Bob Hodges

    I use the term 'review if worse or EVOLVING' in my safety net. It implicitly acknowledges uncertainty in diagnostic practice, and that TIME is part of the process.

    Of course most things go away of their own accord and we are none the wiser. I can live with this.

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  • The single best quote I've heard applicable to GP "medicine is the art of entertaining the patient until the disease fixes itself"

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  • a useful line is 'I know the dangerous things, but I am always seeing odd but harmless things. Lets call it (if they are called Burnett say) 'Burnetts syndrome'.
    somehow that always seems to tickle their ego and they go away happier.
    If they are still unhappy I make a show of measuring it and describing it in great detail as I write the notes. They then believe I am taking it all seriously.....

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  • A not inconsiderable skill is having enough knowledge to know what it “isn’t” and providing that reassurance.

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  • I would ask the patient "Do your teeth itch?".If the patient says "Ah yes" I go on to say "I think you have FITH Syndrome-its quite common and is nothing to worry about".
    (FITH- Fu##ed In The Head).

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  • “Is there perhaps anything else you came here to discuss with me?”
    Or “and how are you otherwise?”

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  • Tom Caldwell

    Tell them it's because of Brexit and that it'll be the size of a 20p piece after we leave the EU.

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