Hamelin: you,ll find something if you look for it



When you have to evaluate a patient with an important disease like a non-Hodgkin lymphoma your reasoning can be biased if you related every new  sign or symptom without a complete physical examination with the main disease. This is true often but not always…


CLINICAL SITUATION: A doctor was paged to attend a hospitalized 72-year-old man with a diagnosis of non-Hodgkin Lymphoma who had received a new cycle of a third-line chemotherapy treatment a week ago. He was at the hospital because he had started with mild fever and lethargy three days before . The family asked  for a doctor because they saw him weak and with an important difficulty to give him his meals.

PHYSICIAN INTERVENTION: In a summary review of the medical records the oncologist wrote that the patient was under response, that means a good evolution with chemotherapy.

The patient was on bed, he answered questions but he was weak and the main incidence referred by the family was that “he could not eat properly because of the pain”. He had mild fever, he has no neck stiffness, no dyspnea. No other findings were detected in the physical examination.

EVOLUTION: The doctor in charge associated the symptoms of mild fever and asthenia with lymphoma. Two days later the patient started to notice a liquid on his mouth. A CAT scan showed a parotideal abscess with gas.

He is now in a complete response and in a good general situation.


COMMENTS AND ANALYSIS: When you are in a rush sometimes you have to get a complete information of the patient in a short period of time. That means that your ability to detect an unusual problem in an unusual location can be altered.

In this case there was  information in the anamnesis to center the symptom around the jaw and also information about a good response of the lymphoma with chemotherapy.

CONCLUSION: the patient usually is telling you the history.  Try to keep a methodic physical examination even in a rushed clinical environment to prevent the presence of a premature closure bias.