Diagnosis

As a medical doctor, what do you do to reassure your patients before telling them to leave hospital? You make sure that your patients understand their diagnosis. Easier said than done. I want to tell my patients what I suspect, and wish that I get it right.

In our clinical practice, we sometimes dare to say that we jump right into the correct answer like what Dr. Gregory House used to do, but not often. On bad days, like today, I knew that I made a mistake.

I'm going to tell you a true story about a young chap I met two weeks ago in hospital. That morning, I was shown his neck with swollen lymph nodes. In the past few days, he'd noticed sore throat, rising temperature and pain in the neck. What I knew was that my colleague had already excluded most infection.

"Now, if that doesn't sound like Kikuchi disease," I told my junior doctor. "I don't know what does." I went on to teach how the disease comes from an immune system going haywire and overactive. I didn't hesitate in the least to suggest my patient go home and wait for the weird disease to die down on its own.

Call it the naïveté of wishful thinking if you will, but it is what I believed and how the self-limiting Kikuchi disease usually behaves.

Two days later, my young patient returned with his parents, looking for me to recount his unremitting fever and neck swelling. I handed them one more prescription and reminded them the appointment to have a needle biopsy of his neck swelling. His mum appeared worried, and told me how another doctor suggested antibiotics for a possible diagnosis of infection.

I nodded. "Indeed. It can be difficult but your son will be better with time." I took a good look at the antibiotics she showed me, and politely said that I won't object to finishing the drug. I was not saying that my patient should get antibiotics. But I was not saying he shouldn't, either.

The overarching message: "I'm open. If you really worry, I can take you back to the hospital. If not, go home and find me whenever you get worse." As I said so, I wrote my mobile phone number on a piece of paper for him to take away. A piece of paper and a sense of you-can-reach-me freedom.

One week passed. The needle biopsy result of his neck lymph node wasn't telling me much. By the time he called me back, his lymph node swelling got more far-flung, spreading to the tummy and groins.

I sighed. "It isn't Kikuchi. I'd better get you back to hospital and will find a way out. Listen, this is more serious than what I'd thought." After few more tests and cutting out one of his lymph nodes, I crossed out the remaining possibilities one by one: from relatively benign Castleman disease to more difficult one like Hodgkin lymphoma. 

By the time I got the final rare diagnosis of anaplastic large cell lymphoma today, I shook my head. It didn't take a genius to notice that I got most thing wrong - except the piece of paper I gave my patient.