In our preclinical education, they teach us the rarest and most interesting cases. Multiple endocrine neoplasias, pheochromocytoma, pilocystic astrocystoma. The more syllables, likely the higher yield it is for Step 1. I’m only partially kidding, but it’s interesting to see just how little of these you will see.
One of my attending general providers on Family Medicine has a picture of her horse above her desk. She reminds me–you hear hoofbeats? Always think horses. Don’t look for zebras. A zebra in medicine is an exotic medical diagnosis that we often study but rarely see. We study them because when we catch a zebra, we don’t want to miss it. Often the prognosis is poor, or the treatment sufferable. So we learn about them, not expecting to see them, but being at the ready just in case.
And on my second week, I caught a zebra. A diabetic patient, uncontrolled, despite swearing adherence to an intense medical regimen of metformin and glyburide, as well as tight glycemic control. We went over her meals and workout regimen. There was no family history of diabetes. Something wasn’t adding up. So we went through the possibilities–was she lying? Type 1 diabetic? Did we check her urine? What other medications or supplements might she be taking? What were her liver and kidney labs like? She was slightly anemic, but nothing that appeared concerning.
But what about a glucagonoma? You know, the one you read about in the textbook. So we sent her for an abdominal CT. And what do you know–a tumor! Not in the pancreas, where you would expect it, but actually in the liver. And it wasn’t metastatic.
Even so, the patient didn’t have NME, a blistering rash commonly associated with the disease. It goes to show you that just how even though we should think horses, never forget about a zebra. So for the holiday, I bought 2 miniature zebras, one for my attending and one for me, to hold onto.