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Zebra Hunting


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So I'm a new grad and just pass my PANCE a month ago and I just finished my 4th day in Family Medicine. So far everything has been going great but something I learned is the rare stuff really is rare. That's what my preceptors always told me and it's something I always think about when I'm formulating my general approach but always keeping the Zebras in my differential. Today I find myself in an interesting situation where I've diagnosed two cases of leucocoria (bilateral eye's both in patients between 8-12 months of age.

 

I get that it's 1:15,000 live births that are affected by this, however, I've spoken to a number of my colleges who have been practicing for years and have never once caught this diagnosis. My complaints were urgent care type complaints but being new Ive made a decision to try and be as thorough so I've just done the general WCC that were age appropriate because you never know when you're going to get these patients to come back in half the time.

 

My question to you all, have any of you guys experienced anything similar? I don't want to be on safari for most my patients, but having made this diagnosis twice within my 1st 4 days in practice has got me questioning this notion of rare really being that rare. I want to have a good balance between being thorough and being efficient, but now I'm spooked a little lol. What ratio would you consider something being from a rare Dx to full on zebra hunting? Any advice is appreciated.

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Congrats on passing the PANCE and starting your career! I am currently in my second year and my interest lies in FM. I don't have an answer to your question, but a challenging aspect that strikes me about FM/IM is having to be on the lookout for literally everything vs. some of the more focused specialities. The adage of uncommon presentations of common diseases present more commonly than common presentations of uncommon diseases floats around in my head, but like you're saying it's hard not to think of zebras, especially after you catch a few.

 

As an aside, I think bilateral leukocoria is less worrisome for retinoblastoma or Coats' disease vs. a unilateral presentation, so there is that. Good luck in FM!

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Some of it depends where you work. In a setting that is academic or has a population that never gets routine check ups, you will see a lot more zebras than working in a suburban clinic where the majority of your patients are not as sick or get sick with the more typical CAD, CHF, lung CA, etc.

 

If it's a thorough H&P then there's no harm and as long as you are not subjecting your patients to harm or unnecessary testing then I think it's fine. You will see some pretty rare stuff in your career but you also will grow to appreciate the nuances in chronic disease management and the "typical stuff." However if it goes to CT scanning and checking vasculitis and rheumatoid labs on everyone of course that's a different story, but obviously what you are talking about is not the latter!

 

I would say always keep your eyes open and it never hurts to include a rare presentation on your differential so long as you focus on the commons. You will find some pretty crazy stuff on occasion but you also have to have some idea of what you're looking for.

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I don't know if I have a great answer, but I agree with winterallsummer. I work in a neurology clinic and further specialize in epilepsy and headaches, although we see a lot of general neurology too. We see more zebras but that's the nature of being in a specialty and even then they are still pretty rare. Even things that you thought you'd see more based on what you learned in PA school aren't that common - for example, I've only seen a handful of true cluster headaches in the last 3 years. 

 

I guess it's using your intuition, especially with very vague complaints. It can be extremely difficult weeding out who has somatization and who has a more rare disorder to explain their symptoms, especially as most people have the former. Common things with atypical presentations can also throw you off. Basically, if things don't add up, symptoms are refractory to medications or treatments that should help, or if there's a family history of similar issues, look further into it. 

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