The reflexes of an emergency room doctor can result in the right diagnosis path thus increasing chances of proper intervention or the wrong path risking the life and health of a patient. Disease diagnosis is definitely a scientific process in essence and the practical approach undertaken thereto is generally akin to an art (Southwood, 2014). From a euphemistic perspective, diagnosis in the emergency room is compared to the traditional sound of hoofs approaching. Normally, the easiest and most probable assumption when a person hears a set of hoofs approaching is that it is a horse. The confirmation that it is indeed a horse leads to the next evaluation on its breed, who is riding it and whether the rider is belligerent. However, if the sound of hoofs is heard and evidence shows that it is not a horse, that is when a ‘zebra’ diagnosis comes in (Southwood, 2014). A ‘zebra diagnosis’, therefore, seeks for a rare and mostly more dangerous disease and is done after the initial diagnosis fails. In some extreme circumstances, even the Zebra diagnosis will fail, leading to the contention that the doctor is facing a major health problem such as HIV or cancer, which will require specialized diagnosis and attention. The two differential diagnoses for the instant case study are Asthma and advent of HIV infection while the zebra diagnosis is Pneumocystis pneumonia (PCP).
Differential Diagnoses
Asthma
When a patient walks into the emergency room complaining of shortness of breath, fever, and non-productive cough, the near-instinctive reaction would be that the patient is probably suffering from asthma. Asthma is a medical condition characterized by the inflammation of the airways of the lungs. Its main symptoms include shortness of breath, wheezing, coughing, and tightening of the chest (Globe et al., 2015). The symptoms of Asthma are considered as intermittent since they are sporadic. The patient may feel normal for a considerable period of time then suddenly fall ill. However, in some instances, the patient may move from having intermittent symptoms and develop an acute asthma attack. In the case study patient, the objective data that rule for this diagnosis is the shortness of breath because that is the most prevalent symptom. Albeit breathing is instinctive and reflex action, the body becomes instantly alarmed when there is a shortness of breath as it can easily lead to death. The subjective data that rule, however include the symptoms of a non-productive cough, fever and night sweats, which can be common symptoms of some types of asthma. A good example of the same would be asthma caused by allergic rhinitis (Ferreira et al., 2014). This confirms the possibility of the patient suffering from asthma as an ab initio diagnosis pending further investigation.
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Advent of HIV Infection
The second differential diagnosis for the case study patient in the advent of HIV infection. The very mention of injective drug use creates the probability of the careless sharing of needles by drug abusers as well as careless behavior which may lead to an HIV infection (Bradley et al., 2014). Indeed, even before a drug abuser who prefers injectable drugs gives the initial complaints, the probability of an HIV infection is high. According to CDC, 1 out of every 36 users of injectable narcotics in America is infected with HIV (CDC, 2017) . Therefore even before considering most of the symptoms, the social factors surrounding the patient creates the objective data that rules for a high probability of an HIV infection. The shortness of breath complained about, however, is not extreme and is mostly only felt after an exertion. This mirrors the shortness of breath that is closely associated with a new HIV infection. Further, the advent of HIV results in a massive replication of the virus as it tries to both survive and take over the body (Hoenigl et al., 2016). This creates the other subjective data symptoms that the patient had complained about such as fevers and night sweat. A non-productive dry cough is also another sign of the advent of HIV. It is, therefore, possible that if the patient is not suffering from Asthma, the patient may be suffering from an onset of HIV.
The Zebra Diagnosis
The Zebra diagnosis takes a mental stretch as well as creative thinking when undertaken in the first instance. Under the current circumstances, the initial complaint before the advent of tests may have created the impression that the patient was suffering from common pneumonia. However, the non-productive cough complained about is a subjective symptom for Pneumocystis pneumonia (PCP) and other fungal pneumonia (Le Bel et al, 2015). PCP only happens to patients with very low immunity such as AIDS patients. The fact that the patient is 31 years old and using injectable narcotics means that the patient may have used injectable narcotics since teenage. The patient may, therefore, have contracted HIV and due to neither having been diagnosed nor being put under antiretroviral therapy, the patient may have acquired AIDS (Maartens et al, 2014). The objective data for this diagnosis is the shortness of breath, which has been progressive over a month and getting worse, and can be indicative of the progress of PCP. Albeit PCP has a very high mortality rate, it has a relatively low development rate with its duration being several weeks depending on the immunity of the patient. Further, the objective data for zebra diagnosis for PCP can also be supported by the interstitial infiltrate in a “bat’s wing” or “butterfly” pattern found in the lungs (Robert-Gangneux et al., 2014). The relatively high fever may also point away from asthma and HIV advent diagnosis and towards PCP. Therefore, upon further investigation, as shown above, the Zebra diagnosis gets more credence than the horse diagnosis.
The Most Important lesson Learnt from the Case Study
The instant case study provided an opportunity for intensive research on the subject of HIV and AIDS. Through the case study, I was able to learn the most important lesson of proper diagnosis as many diseases present similar symptoms. If a singular diagnosis is taken without taking into account others that can present similar symptons, a patient is likely to be given wrong medication. In regard to the case study patient, unless a diagnosis is made and control measures such as administering Active Antiretroviral Therapy, viral replication will continue in the body until the patient develops Acquired Immune Deficiency Syndrome (Ooi et al, 2015). When a person has AIDS, they are susceptible to diseases that are too weak to overcome normal human immunity such as PCP. However, even after the AIDS has developed, the situation is not desperate as a patient can still be treated with highly active antiretroviral therapy” or HAART and recover immunity (Maartens et al, 2014).
Conclusion
In the ER, there is an exponential variety of possibilities regarding what a walk in a patient may be suffering from when the visit has not resulted from a physical injury. It is, therefore, incumbent upon the ER doctor to make a proper potential diagnosis on what may be affecting the patient to enable a better understanding on what further tests should be undertaken. In the instant case, the patient has a shortness of breath that has a history of over 30 days. The shortness of breath seems to have been progressive leading to the ER visit. Social particulars of the patient show a history of injectable narcotic use, which is closely associated with HIV and AIDS. The ER doctor must balance between rushing towards the easier possibility that the patient has an HIV-related complication albeit without ignoring the fact. It is on this that the horse diagnosis is based on an HIV and non-HIV related ailment. The zebra diagnosis is premised on the rarer AIDS related ailment. Based on the three possible diagnoses , further tests are likely to arrive at the right diagnosis.
References
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CDC. (2017, March 16). HIV/AIDS. Retrieved from https://www.cdc.gov/hiv/risk/idu.html
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Le Bel, J., Hausfater, P., Chenevier-Gobeaux, C., Blanc, F. X., Benjoar , M., Ficko , C., ... & Claessens, Y. E. (2015). Diagnostic accuracy of C-reactive protein and procalcitonin in suspected community-acquired pneumonia adults visiting emergency department and having a systematic thoracic CT scan. Critical Care , 19 (1), 366
Maartens, G., Celum, C., & Lewin, S. R. (2014). HIV infection: epidemiology, pathogenesis, treatment, and prevention. The Lancet , 384 (9939), 258-271
Ooi, C., Rogers, G. D., & Couldwell, D. (2015). Assessment of the patient with chronic HIV disease. In HIV, Viral Hepatitis and STIs: A Guide for Primary Care . Australasian Society for HIV Medicine publishers
Robert-Gangneux, F., Belaz , S., Revest, M., Tattevin, P., Jouneau , S., Decaux, O., ... & Gangneux, J. P. (2014). Diagnosis of Pneumocystis jirovecii pneumonia in immunocompromised patients by real-time PCR: a 4-year prospective study. Journal of Clinical Microbiology , 52 (9), 3370-3376
Southwood, L. L. (2014). The challenge with diagnosing rare diseases: The ‘zebra’ diagnosis. Equine Veterinary Education , 26 (10), 559-560
