How do you know when generic symptoms are masquerading as something serious? Hear the story of Molly Lalonde, a pediatric nurse practitioner, who met an 11-year-old patient with an unexpected concern. While surprised by the patient’s inquiry, Molly took the time to listen and ask questions. In response to the patient’s heightened level of concern, Molly investigated further. Following an assessment by a specialist, it turned out the patient’s concern was warranted. So how do you recognize the zebra in a herd of horses? To get another perspective, our host Connie spoke with Dr. Raj Bhardwaj, an urgent care physician and host of the DDx podcast. Dr. Bhardwaj details how to zoom out and get the bigger picture, the importance of respecting the concerns of your patients (just as Molly did), and following your spidey sense.
Molly Lalonde is a certified pediatric primary care nurse practitioner and pediatric mental health specialist in Colorado.
Dr. Raj Bhardwaj
Dr. Raj Bhardwaj is a family medicine and urgent care physician in Alberta Canada. He is also a clinical assistant professor with the Department of Family Medicine at the Cumming School of Medicine at the University of Calgary. He hosts the award-winning podcast, DDx, a podcast about how doctors think. He also hosts various programming for CBC Radio and CBC Calgary News.
DDx SEASON 8 | They Don’t Teach That in Nursing School, EPISODE 1
WHEN GENERIC SYMPTOMS TURN SERIOUS
MOLLY: The patient who walked in my door, it was an 11-year-old male. He came in with his father, and the chief complaint that was actually listed was cold symptoms. When I walked in, I said, ‘Oh, when did you start feeling sick?’ They looked at me and said, ‘That’s not why we’re actually here.’ Which, as a clinician, you’re, you know, the pit of your stomach goes out and you’re like, oh my gosh, what’s going to happen?
Their actual chief complaint was that they were concerned that the patient’s penis was too small. He had been around his cousin who was a similar age. They had changed clothes. And based on that, his specific concern was just that his penis was too small. He wasn’t having any urinary symptoms, no other kind of concerning features.
Just strictly, you know, what kind of seems like an emotional concern. In other cases, I wouldn’t push for further investigation, but I think it was their level of concern and really just listening to that and almost like feeling that is what made me feel like there was something more to this situation.
And the moment I read the diagnosis that the patient got from the specialist, I was shocked. Mostly because he had been a really normal appearing patient.
CONNIE: Meet Molly. She’s a 39-year-old pediatric nurse practitioner in Colorado.
And while this problem was staring her straight in the face, the solution was not.
MOLLY: I think the biggest problem was kind of the discrepancy between what I was seeing versus what the patient was telling me and how distressed they were. That’s one of the core struggles with primary care, is like, what’s the variation of normal and what’s something that requires more investigation? And in the back of my mind, I go like, well, they don’t teach you that in nursing school. So you kind of have to change your game plan because you don’t really have one in a lot of cases.
CONNIE: This is, They Don’t Teach That in Nursing School, a podcast from Figure 1 about how nurses think.
I’m Connie Levie.
After 16 years at my hospital in the nuclear medicine department, I was ready for a change.
COVID had just hit and I saw my nurse friends struggling.
I decided to go to nursing school — so I could help out.
After years in medicine, I’ve learned the most essential lessons are the ones that you learn on the job, and that’s exactly what this show is about.
This is a show where we provide unique practical solutions to some of the most challenging problems nurses face.
From learning how to operate a ventilator during the height of COVID, to dealing with an attending physician who’s a bully.
We’ll be sharing the secrets of the trade from nurses, doctors, medical researchers, all the professionals you wish you could consult but rarely have the time or opportunity to.
You’ll feel seen, gain wisdom, and be better equipped to respond to all the unpredictable stuff that gets thrown at you.
Today’s case is all about what to do when generic symptoms turn serious, and how to spot those symptoms before they become critical.
Our case comes to us from Molly Lalonde, pediatric nurse practitioner in Colorado.
After listening to her patient and asking questions, Molly did an examination.
MOLLY: I did a genital exam, he was 11, prepubertal. His genitals fell with what I would consider normal. You know, I told dad and the patient that but just saw this look in their eye. I could tell they still felt there was a problem.
CONNIE: Molly referred the family to a urologist.
MOLLY: And at that point, since he wasn’t having symptoms, it fell out of my mind until I got the note back from the specialist.
And I remember reading it and the specialist note essentially said what I had felt, which is, the parents are really concerned, the patient is really concerned. What I see looks normal.
CONNIE: At first, the urologist didn’t find anything to be concerned about. But before we continue, let’s add another perspective to this conversation.
As a nurse, one of the things we rarely get time to do is consult with other medical professionals about a challenging case. So let’s do that now.
Raj Bhardwaj is an urgent care physician and host of DDx, another show we produce that’s all about being able to recognize that zebra in a herd of horses.
With only the initial details of the case, Raj walks us through the first steps on his diagnostic journey.
RAJ: I have a general approach, which is get as much of the story, of the patient’s story, as I can before I start to narrow my differential diagnosis. I really want to build it. The first thing I would do is zoom out.
Right away I’m thinking, okay, first of all, is this something physical or is this something more sort of expectation based, maybe mental health based, things like that. So that’s the first thing I would get into is tell me more about, about not just your concerns but the rest of your physical, you know, life.
You know, right from birth and development to the family history, you know, like all sorts of things can be clues when you’re thinking with such a broad differential. The other thing that I would make sure to do is a full physical exam, but I would, again, zoom out and say, okay, this kid is concerned about a small penis, what else is going on with his body? I would leave the general exam to last. Again, partly because I want the context and partly because I want this kid to be comfortable with me doing a genital exam. I don’t want to just jump in and, and go straight there.
MOLLY: I think sometimes you get so many patients who come in for so many different things. And it’s, sometimes you feel like your caliber is off a little bit, like you missed something. But this really was one where I went, okay, my gut was right about this. I felt like I was doing a part of my job that we forget about, which is really like listening to our patients and supporting them and not just brushing off concerns they have.
RAJ: I love that Molly listened to and respected the concerns of the patient and the parent. She also listened to and respected her own spidey sense, you know, that there’s something going on here. And to think, you know, these folks are really concerned, that’s enough for me to also be concerned, even though everything seems reassuring. And, and I think that’s how I would play it. You know, to say, ‘Look, everything seems reassuring to me, but let’s have somebody else have another crack at it.’ And, to listen to that spidey sense, because a lot of times that saves us.
CONNIE: Luckily, the urologist that Molly referred the patient to also listened to their spidey sense, which pointed them in a direction that ended up being crucial for this patient’s diagnosis.
MOLLY: I think, thankfully, they had that same gut instinct that I had, which was that there’s something else that might be going on, and they ended up doing a karyotype on the patient, which was really, again, the only test that they could do.
CONNIE: A karyotype is a kind of genetic testing which examines the size, shape, and number of chromosomes in a cell sample from a patient.
MOLLY: And thankfully, they did that because the patient ended up having Klinefelter syndrome. Klinefelter syndrome is where a male is actually XXY, not just XY. So he essentially had an extra X chromosome. The signs are often pretty subtle, and so again, it’s not something that’s super obvious when, necessarily, when people are born, but it’s definitely something that can have pretty profound and pretty widespread impact just because it does deal with the chromosomes.
CONNIE: When the patient and his family heard the diagnosis, they were relieved. They felt listened to and validated, and the patient started hormone therapy and additional treatment.
There’s no shortage of lessons from a case like this. Let’s go back to Molly and Raj to hear about what’s stuck in their minds.
MOLLY: You see so many horses versus zebras, especially in primary care, that you do start to sort of presume that if it looks like a horse and it sounds like a horse it’s probably a horse because a lot of times it is. So it takes some practice and some experience, and it’s hard. I don’t know how it would be something to teach or how you gain that without just sort of seeing a lot of patients and sort of really getting into that kind of granular part of: What’s the difference between something that is normal and something that requires, like, further steps.
RAJ: I think a lot of it is understanding the context, which means understanding the big picture, and again that brings me to zooming out, and having a broad knowledge base to draw on so that we’re reminded that, you know, there are uncommon conditions and there’s uncommon presentations of common conditions that you can remind yourself of and have a chance to recognize them.
MOLLY: I think sometimes too, we really focus on diagnostics, but sometimes the diagnosis isn’t what they want or need. They might already kind of know it or suspect it, but I think if you really go into it and, and are there to like, not only ask them questions, but sort of explain to them, this is why I’m asking you these things. I think that helps a lot. Listen to your patients is to me the most important thing. I felt like I was doing a part of my job that we forget about, which is really like listening to our patients and supporting them and not just brushing off concerns they have.
RAJ: And listen to your gut, you know, every once in a while, it’s going to be right.
MOLLY: I always go back to that case personally because it was kind of early in my career in a case where trusting my gut and listening to the patient really ended up being valuable and that sometimes even though your examination is normal and you’re not seeing anything specific that not letting that shut the door.
RAJ: It’s the spidey sense that makes you think you know there’s just something going on about this that I just I don’t think it’s as straightforward as it seems on first blush, it’s like there’s one little neuron in my head that says, wait a minute, this sounds familiar, you know, and maybe it was like two paragraphs in school in first year, but it’s like, hmm, there’s something there. And then, you know, I think that, and then you sort of chase that down.
MOLLY: When you get that, like, tickle in your brain or your gut tells you something, follow that. It might end up being that, nope, it’s normal and everything’s fine, but at least you can go back to that patient. And for your own self and your own knowledge, you can really say, like, I did everything. I went through the full process. And in this situation, it really felt like it was necessary and that the patient benefited from it.
CONNIE: Thanks to Molly Lalonde and Raj Bhardwaj for speaking with us.
This is They Don’t Teach That in Nursing School, a podcast by Figure 1.
Figure 1 is an app that lets healthcare professionals share knowledge to improve patient care.
I’m Connie Levie, your host and partner on this journey.
Thanks for listening!