Grand Rounds Report: Clinical Pathologic Conference

by Academy of Clinical Excellence on December 22, 2010

Of all the formats of Grand Rounds, Clinical Pathologic Conferences (CPCs) are my favorite as they move through a nice progression of a resident presentation of clinical data, followed by a discussion led by a scholarly physician, and finally ending with a pathologist who provides the punch line (that is hopefully the answer provided by the scholarly physician).This past week’s Grand Rounds followed this pattern, but provided more clinical acumen than usual.

There was a unique aspect from the start, as the widow of the unfortunate deceased patient was in the audience.She was introduced at the start and spoke most eloquently at the end.The case was that of a 52 year old man who presented with a few day history of a seemingly innocuous upper respiratory infection that progressed to more significant right ear and neck pain.Once admitted to the hospital, neck swelling became quite prominent and imaging showed a massively enlarged thyroid.Despite broad spectrum antibiotics, the patient developed sepsis and died.

The discussant was Dr. D. William Schlott, Philip A. Tumulty Associate Professor of Medicine.His discussion was led off by his reminiscing about how it had been 50 years since he first had been at Johns Hopkins Bayview Medical Center (then Baltimore City Hospital) as a medical student.He discussed how from early in his career, he was always encouraged to go see patients (even if he was not caring for them) who had an unusual physical finding or an unusual illness.He related that he had never seen a patient presenting like the current case, with massive thyroid enlargement and a picture of sepsis.

When charged with figuring out the case, he first turned to the internet, to peruse the literature.He was fairly certain the diagnosis was suppurative thyroiditis, but to make sure, he took a crucial second step, “turning to a partner in medicine.”He sought out who he believed was the best clinical radiologist and had him look at the patient’s neck CT with him.The radiologist agreed with the diagnosis and was able to point out findings specific to the diagnosis.However, at the same time, Dr. Schlott did caution that too often physicians rely on imaging, rather than clinical sense.

This was one of those Medical Grand Rounds that made me reflect on the beauty of medicine.Even after 50 years of practicing medicine, a master clinician had just discussed and made a diagnosis of something he had never before seen.

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