Editorial

Abstract

Over the course of our careers we will see many thousands of patients, but there are one or two who we remember vividly; it is often these patients who shape and change our practice most. The problem-based review written by Kevin Jones’ team in Bolton in this edition reminded me of one of the first patients I clerked as a medical Senior House Off icer, while working in a District General Hospital back in the early 1990s. I was revising for the written part of the MRCP Part 2 examination at the time, so when the general practitioner described the young man’s fatigue, low grade fever and rash as ‘probable viraema’, my thoughts immediately turned to far more esoteric diagnoses. For once my suspicions were confirmed. The ‘fatigue’ was clearly proximal myopathy with marked tenderness suggesting a myositis; his rash had the typical ‘heliotrope’ distribution accompanied by nail-fold oedema; the diagnosis of dermatomyositis was sealed long before the consultant ward round when the laboratory phoned through his Creatinine Kinase result of over 15,000. I remember the feeling of elation at having made the diagnosis, the metaphorical pat on the back from my consultant and the look of relief in the eyes of the patient and his mother when I told them that we had the answer. I had no doubt in my mind that the hydrocortisone I had prescribed would rapidly improve his symptoms allowing him to resume his usual activity within a few weeks – I had read all about it in Kumar and Clark or some other erudite medical text book. For a few hours medicine was wonderful – until my cardiac arrest bleep went off. CPR was already in progress when I arrived on the ward; I had attended resuscitation calls before, but never for an 18 year old. A nurse reported that he had complained of dyspnoea and became drowsy shortly before he stopped breathing. There was a cardiac output, but no respiratory effort – he was intubated, ventilated, transferred to intensive care and then to a regional specialist unit, but sadly never regained consciousness before he died 2 weeks later. This was a tragic story which affected many people, but which taught me a really important lesson: making a diagnosis is where our job starts – not where it ends. We will never know whether we could have made any difference to this poor young man by anticipating a different outcome, closer monitoring of his respiratory function or earlier involvement of our critical care team. The speed of his deterioration was such that even today’s focus on early warning scoring and prompt recognition of changes in physiology, which has developed over the past 2 decades, would probably not have changed his outcome. However the key is to expect the unexpected; there are formes frustes of many conditions which behave differently to those which appear in the text books. Making a diagnosis should never be a cause for celebration.