Several years ago when I was an Intern, I was chit-chatting with Dr. Sambita Chakravarty in the Pediatrics duty doctors' room. A bearded-man in a knee long panjabi with his wife peeked through the door. The wife had their son on her lap. He was Jamal. 8 years. The man had an anxious face- definitely for his son. I couldn't see the face of the wife as it was covered in a Burqa. She must be anxious. After all she was a mother.
I asked, 'what is the problem?'
Jamal had a fever for about a week. But his main problem was he had a pain in a specific site of the right chest. Sometimes the pain became unbearable.
I looked at the face of Jamal and became a bit surprised. The normal skittishness of an eight years old was absent in him. He behaved like a sixty years old. He had black eyes and nicely combed hair.
His parents went to consult a professor of Internal Medicine (who was also my teacher). The professor advised him an X-ray and blood test. There was a classic textbook image of lung abscess in the X-ray and an elevated WBC count in the blood test. Following investigation, the professor advised the parents to get Jamal admitted in the pediatrics department. As a result, I got to meet Jamal and his family.
I carried Jamal to the examination table. There were typical findings of lung abscess. We got him admitted.
Next day, in the morning session, we told Prof. Dr. Barun Kanti Biswas, head of the Pediatrics department that a boy was admitted with lung abscess in the previous afternoon. Prof. Biswas listened to the history of the patient. He then asked Jamal, 'what is your name, boy?' Jamal answered, 'Jamal'. He asked again, 'Which class are you in?' Jamal answered, 'in class two.'
Then Dr. Biswas looked at us and said, 'this is not a case of lung abscess.'
We showed him the X-ray. He looked at the X-ray for a while and then said, 'this is not a case of lung abscess. Advise an ultra-sonogram of the chest.'
We took Jamal to the Radiology and Imaging department. Following USG, the report came- a case of lung abscess.
We notified the professor about the USG report. He looked at the image and said, 'whatever in the report, it is not a case of lung abscess. Advise a CT scan of chest'. We looked at Prof. Biswas and scratched our head. CT scan is an expensive investigation.
However, we managed to go for CT scan.
In the following day, Dr. Biswas himself had asked, 'what is the CT report?'
-Benign developmental cyst.
-Yes. This patient needs surgery. Treat him accordingly.
We asked Prof. Biswas, why did he thought it was not a case of lung abscess in the presence of so much supporting evidences? He answered, 'because I could talk with the patient. If it was a lung abscess, you couldn't talk with the patient due to the foul odor.'
While reading this book I was thinking of Prof. Biswas. The author explained with example after example, how can a small overlooked clue change the diagnosis? How each and every components on the path to diagnosis is important? For instance, in this case of Jamal, several diseases could make this problem- we doctors call them differential diagnosis. Lung abscess was one of the differential diagnosis and the most probable one. Dr. Biswas changed his diagnosis only with a simple clue. 'I was not amazed because he was right. I was amazed because of his thinking.'
Dr. Sanders said, 'thinking stops when a diagnosis is made'. And sometimes a very tiny clue becomes the most important one.
Highly recommended for the doctors.