Atlas of Uncommon Pain Syndromes 3e PDF

Atlas of Uncommon Pain Syndromes 3e PDF

It has been said that the three most dangerous things in medicine are (1) a medical student with a sharp object, (2) a resident with a recently published study from the New England Journal of Medicine, and (3) an attending physician with an anecdote. One must suspect that point 2 was at play when in the 1940s while on rounds at the University of Maryland Hospital in Baltimore, Maryland, Theodore Woodward, MD, stated, “If you hear hoof beats out on Green Street, don’t look for zebras”! How this admonition to aspiring physicians morphed into when you hear hoof beats, look for horses, not zebras” is anybody’s guess. (My son, an ophthalmology resident in Baltimore, suggests that it was also just as likely that this sage piece of advice was accompanied by a long-winded and confusing anecdote—see point 3.)
On the surface, most of us would agree with Dr. Woodward’s logic that the most common things are the most common. Occam agreed, when in the fourteenth century he put forth the philosophical tenant of parsimony, which proposes that simpler explanations are, all things being equal, almost always better than more complex ones. He used a razor to “shave away” unnecessary or extraneous data to get to the simplest solution. The razor was all the rage as a medical instrument in the fourteenth century, so it is not surprising that Occam chose it as his preferred medical device. Occam’s razor certainly has a nice ring to it—better than Occam’s MRI, which would no doubt be the name of his maxim if he had lived in the twenty-frst century, given that currently the MRI is certainly our most popular medical device for “shaving away” extraneous data.
Which brings us to KISS—not the Gene Simmons rock band KISS, but the admonition “Keep it simple, stupid.” KISS was set forth by Lockheed aeronautical engineer, Kelly Johnson, when he handed his design team a few simple tools and challenged them to design combat jets that could be easily fxed with the simple tools that were available in combat situations. It is still not exactly clear to me who was “stupid,” but I certainly hope it is not the guys who fx the jets I fly on. KISS makes sense when designing jet engines, but what does this have to do with the individual patient?
The sick one? The scared one? The one you worry about in the middle of the night? Unfortunately, very little. Because for the individual patient with a diffcult diagnosis, Hickam was probably more correct than Occam. Harry Hickam, MD, while on teaching rounds at Duke University, admonished his students and residents that “Patients can have as many diseases as they damn well please!” (also see point 3).
He correctly posited that when diagnosing the individual patient, using Occam’s razor often provides the correct diagnosis. More often than we would care to admit, though, when dealing with a patient with a perplexing constellation of signs and symptoms, it can provide the wrong one. In fact, overreliance on Occam’s razor can be downright dangerous for patient and physician alike. Often, the simplest, or in the case of medical diagnosis, the most common, illness is exactly what is causing the patient’s symptoms.
But sometimes, in our almost obsessive desire to make the diagnosis, simplicity is our enemy. In our haste to make the patient ft the diagnosis, we get it wrong. Uncommon diseases are called uncommon diseases because they are uncommon—they are not called unknown diseases. Since the beginning of time, healers have recognized that the correct diagnosis is the key to getting the patient well, and, as a corollary, they also realized that the wrong diagnosis is not a “practice builder.” Which brings us to country music legend Mickey Gilley. In 1976, Mickey Gilley recorded the classic country ballad “Don’t the Girls All Get Prettier at Closing Time,” a plaintive lament about loneliness and late-night desperation and how one’s perception of things can change as circumstances change. What turns an unknown disease into an uncommon disease is knowledge. What changes our perception of what a constellation of symptoms and physical fndings mean when confronted with a perplexing diagnosis is knowledge. As we gain more clinical experience, things that were once unknown become known, even commonplace.
The more we hone our clinical acumen, the easier it is to put the pieces together. Our perception of the diagnostic information our patients present us with changes from a jumble of disparate signs and symptoms to the certain diagnosis of an uncommon disease—one that we will never miss again! Atlas of Uncommon Pain Syndromes, Third Edition, seeks to accomplish three things: The frst is to familiarize the clinician with a group of uncommon pain syndromes that occur with enough frequency that they merit serious study—not rare or orphan diseases, just uncommon ones that are often misdiagnosed. Second, this text is written with the goal of helping clinicians reinforce their knowledge of common pain syndromes to help in those situations when Occam is sort of correct—when the pieces of the puzzle do not quite ft the simple diagnosis. The third goal is more about the clinician and a little less about the patient. It is about what attracted many of us to medicine to begin with. It is the irresistible charm of being presented with a diffcult clinical problem and getting it right. And what a great feeling that is! I hope you enjoy reading the third edition of Atlas of Uncommon Pain Syndromes as much as I did writing it

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