A retired polysymptomatic man attended surgery with his wife describing “adrenaline rushes,” 15 minute periods of flushing, palpitations, and overwhelming anxiety. These had been occurring for many years but with increasing frequency. His wife attributed this to his “nerves,” something he strongly denied. A brief scan through the man's notes gave the impression of a frequent attender with a history of anxiety disorder, hypertension, hyperlipidaemia, and arrhythmia, with numerous outpatient visits and cardiac investigations to his name.
He requested an adrenal scan to look for the source of all his adrenaline. “Extremely unlikely to yield any valuable information,” I informed him, opting instead for a cardiology referral for consideration of an event recorder and adjustment of his antiarrhythmia treatment.
Fortunately, the cardiologist was alert, and two tests for urinary catecholamine concentration have revealed phaeochromocytoma, with a pending MIGB (131I-metaiodobenzylguanidine) scan to guide further management.
What have I learnt from this? Firstly, history taking, the first clinical skill learnt at medical school, underpins all diagnoses. In among this patient's numerous complaints lay a textbook description of a period of crisis from a sympathetic tumour. The poor historian was not the patient but the doctor, for my inability to interpret the information presented in an unbiased way.
Secondly, although common things are common, rarities do occur and are equally likely to arise in a patient previously labelled with a psychiatric disorder.
And finally, although prior knowledge of a patient's history can guide the consultation, it may also prejudice its outcome.