Isn't the problem with this sort of thing that there are far too many
variables and interpersonal variations in the history and exam to be
able to approach such rare diagnoses by deductive reasoning. What you
are left with then for the "expert" system (ie. experienced clinican)
is pattern recognition (if you are lucky) which is a sort of fuzzy
matching ... I saw something a bit like this 10 years ago, and funny
enough he was a plumber too, though he wasnt from Surrey. Might be
worth checking the serum rhubarb..
I think we just have to admit that when stuff is very rare, or
presents atypically our "play the odds" approach will mostly be wrong.
I admitted 2 possible cases of endocarditis last month. One was ill
with rigors, raised WCC, CRP and ESR and new murmur. The second was
also ill with rigors and pre-existing MVD.
Neither were. The next one will come with 3 weeks malaise following
URTI and I'll bat it away :-(
On 8 March 2010 09:56, Holmes Alistair (WEST SUSSEX PCT)
<[log in to unmask]> wrote:
> -----Original Message-----
> From: GP-UK [mailto:[log in to unmask]] On Behalf Of Julian Bradley
> Sent: 05 March 2010 22:15
> To: [log in to unmask]
> Subject: Re: A story - part 4
>
> Is this story of any use -
> J
>
> John has a point it must be rare, however, it made me think and at least endocrinology was the right speciality. Thinking is probably a good thing hopefully one improves with practice, it is interesting that one's first response of these sort of stories causes illumination of cases you thought you had long since forgotten as a bit like that one then and then the analytical thinking occurs after. One of the conundrums of General Practice is that while common things are common, because there are so many rare things then you see rare things commonly, in someways it is the ideal post for an ex train spotter ( not that I did that ) even common things can have rare presentations such as stroke caused by intra_arterial disection, one should occur to your list every 50 years or so. There is a fine balance between revising the rare enough that one has a hope you might get it, and doing so much you cease to be able to see the sapling in the forest. I will admit I have still no ruler against which to measure how to do that balance. It is a similar issue to how do you collect, of what information, of your practice that allows deliniation of the 4th Johiri square in order to be able to shrink it. The insight of others on their rulers/information gathering would be helpful. ( Note while it should be, this is not the revalidation exercise which is something completely different)
>
> Alistair
>
>
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