Wilfred Trotter, an English surgeon, once said: "Disease often tells its secrets in casual parentheses." This implies that we need to observe and listen carefully, often over a period of time, without prematurely concluding that we know what the problem is, if we are keen to make a correct diagnosis. In the Malaysian Family Physician there is a report of a young patient who presented with mild arthritis of the ankle joints after a short febrile illness.
I asked myself what I would have diagnosed at that point. I think I would have considered it to be part of a viral syndrome but would look carefully for evidence of septic arthritis.
A few days later this patient developed erythema nodosum - a localised painful inflammation of the subcutaneous tissue. Since erythema nodosum is the result of an immune response, I would at this stage have considered the possibility of a reactive arthritis and looked for infections in the urinary tract, gastrointestinal tract and also for streptococcal infections in the throat.
This case report in the Malaysian Family Physician has made me realise that the disease the patient really has is not what I am thinking about. The correct diagnosis revealed itself to the doctors only after yet more time. This appears to validate what Wilfred Trotter said.
Read the case report in the Malaysian Family Physician
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