Unexpected Closure.
Unexpected Closure.
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DOI：
10.1056/nejmp2119328
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发表时间：
2022-06-23
影响因子：
158.5
通讯作者：
Tedeschi, Sara
中科院分区：
文献类型：
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作者：
Tedeschi, Sara
“一旦你做出诊断，你就停止思考。质疑自己的诊断，这样你就永远不会停止思考，并记住鉴别诊断的一部分是你错了。”罗纳德·安德森 (Ronald Anderson) 博士在我们风湿病学研究员的工作室中发布的众多课程之一是这样读到的。罗恩是我们的名誉项目主任，他是一位出色的临床医生和教育家，他精辟的教学要点塑造了无数风湿病学学员的思想。我们将这些临床珍珠称为“罗恩主义”。罗恩建议我们，“永远不要害怕告诉病人你不知道他们有什么，但他们在正确的地方。” 2015 年 C. 先生住院时，我遇见了他。我是咨询小组的风湿病学研究员，被要求确定他是否患有巨细胞动脉炎 (GCA)。尽管他的一些症状和实验室检查结果（体重减轻、颞部头痛、视力模糊、红细胞沉降率和 C 反应蛋白水平极度升高）提示患有 GCA，但其他因素却令人困惑。眶周肿胀和压痛是他最严重的两个症状，但并不是 GCA 的典型症状。他的记录显示了通常与 GCA 无关的异常情况，包括肺门和纵隔腺病、May-Thurner 综合征、HLA-B27 阳性、葡萄膜炎和骶髂关节强直。更复杂的是，自 2012 年以来，他一直在服用中等到高剂量的泼尼松来治疗他的膝盖痛风，这让我怀疑其他炎症症状是否被掩盖了。正如罗恩所说，总体诊断是“我不知道”。
“Once you make a diagnosis, you stop thinking. Question your own diagnosis so that you never stop thinking, and remember that part of the differential diagnosis is that you are wrong.” So reads one of the many lessons from Dr. Ronald Anderson posted in our rheumatology fellows’ workroom. Ron, our program director emeritus, is a masterful clinician and educator whose pithy teaching points have shaped the minds of countless rheumatology trainees. We call these clinical pearls “Ronisms.” Ron counsels us,“Never be afraid to tell a patient that you don’t know what they have but that they’re in the right place.” I met Mr. C. when he was hospitalized in 2015. I was the rheumatology fellow on the consult team asked to determine whether he had giant-cell arteritis (GCA). Although some of his symptoms and laboratory findings—weight loss, temporal headache, blurry vision, and extremely elevated erythrocyte sedimentation rate and C-reactive protein level—suggested GCA, other elements were perplexing. Periorbital swelling and tenderness, two of his worst symptoms, were not typical of GCA. His record revealed abnormalities not usually associated with GCA, including hilar and mediastinal adenopathy, May–Thurner syndrome, HLA-B27 positivity, uveitis, and ankylosis of the sacroiliac joints. Further complicating the picture, he’d been taking moderate-to-high doses of prednisone since 2012 for what was assumed to be gout in his knee, which made me wonder whether other inflammatory symptoms were being masked. As Ron would say, the overarching diagnosis was “I don’t know.”