“When you hear hoofbeats, think horses, not zebras,” -Dr. Theodore Woodward
Dr. Woodward coined a phrase repeated time and time again to students. From early on, medical professionals learn to think common symptoms develop from common complaints. While the atypical diseases stick out in our minds, the likelihood of seeing them is rare.
But rare does not mean absent.
Walking into the exam room, a young man sat in the corner with his head down and eyes deflected. Next to him, his mother attempted a forced smile while thanking me for working in this new patient. His symptoms were getting worse, and she worried another two weeks of waiting might force an emergency room visit.
She described problems with constipation.
My initial impression centered on a teenager who preferred not to have a bowel movement away from home. I tried to remember back to high school, with complications of youthful shyness and teasing that accompanies certain bodily functions.
Hoof beats, I thought, must be a horse.
I theorized this young man was the brunt of past adolescent jokes contributing to development of his reluctance to use a high school restroom.
He explained nausea, and a decreased appetite followed his bouts of constipation.
A local urgent care visit two weeks earlier sent him home with a gentle laxative, instructions to stay hydrated, and eat plenty of vegetables; something every growing boy loves to hear. His condition, however, didn’t change following this advice and his mother’s concern grew.
My young patient wasn’t in any distress, so I sent him for an abdominal x-ray, drew labs and suggested he use the bathroom before going to school. Adding a fiber supplement to his diet might help.
The x-ray was normal and the labs; unremarkable, so watchful waiting seemed in order.
About two weeks passed before the patient and his mother appeared once again in my exam room. His symptoms showed no improvement, and he now felt much more bloated.
His mother’s pursed lips and quiet voice described the persistent nature of her son’s complaints.
And this visit, his physical exam was much more disturbing.
He was 10 lbs heavier and his abdomen was firm. His discomfort was clear.
I discussed my new apprehension with the patient and mother regarding the rapid change in his physical presentation. We reviewed our options, and I scheduled him for a CT scan of the abdomen and pelvis the next day.
The results surprised the radiologist who called me before the patient was off the table.
“There is a very large volume of ascites filling the peritoneal cavity across the liver and splenic margins through the pelvis,” he said. “The liver, spleen, pancreas and kidneys show no masses. At the base of the small mesentery at the level of the pelvic rim, there may be adenopathy over 3 to 4 cm centrally. I believe this should raise concern, given I see no convincing reason otherwise for the ascites.”
Medical speak for, “There’s fluid in places that shouldn’t have any and unusual swelling in places not supposed to swell.”
I called one of the local gastroenterologists, who agreed to see the patient the following morning.
After his initial examination and further lab work, he decided endoscopy and a colonoscopy would be necessary to further evaluate the elusive cause of this young patient’s abnormal CT scan findings.
The endoscopy was unremarkable.
His colonoscopy, however, prompted another “same day” phone call to my office, no less surprising than the last one.
“The patient’s preparation appeared excellent. The endoscope made it in about 30cm, with any further exam blocked by an obstructing colon mass which was very hemorrhagic in nature,” the gastroenterologist said.
He took multiple biopsies and we waited for results.
The pathology report was heart-wrenching; Adenocarcinoma. A fancy way of saying colon cancer; not something ever expected in a 17-year-old.
These hoof beats were from a zebra; and my heart broke for the patient and his parents.
Someone who has not walked this path can never fully appreciate the pain and fear that comes with a cancer diagnosis. It struck a chord with me however, having a son also diagnosed with cancer a few years prior.
I sent the patient to a nationally recognized treatment center where he underwent exploratory surgery.
The report from the oncologist gave us a final perspective.
They found this healthy-appearing young man to have a stage IV disease. The experts told them even with all our medical advancements, their only options was comfort care for a colon cancer this far advanced.
With the greatest medical minds providing the best care on earth, this young man lived two more years before falling to the disease.
Many years later, this case remains fresh and serves me well as a constant reminder life is fragile, regardless of age.
It keeps me vigilant to complacency, not only in medical circles but also in everyday life.
Dr. Woodward was right, common things come from common sources.
Still, we need to keep our eyes open; never casually dismissing a tugging feeling that asks us to look another direction. Even if the glance is brief, considering atypical solutions to challenging issues gives us a potential for life-changing opportunities we may otherwise miss.
I need to be careful not to chase the zebras, but still I must be ready to catch one if it wanders by.