Snap Diagnosis

At the nursing home the other day I saw a young man in blue scrubs push a laundry cart up the hall. He must be new, I thought, trying to catch a glimpse of his name tag. As he approached the nurse’s desk he made a sudden noise.

“Bless you”, one of the nurses said.

The young man smiled briefly. “I didn’t sneeze, but thank you. I am probably the most blessed person around.”

I wasn’t sure what that little exchange was all about and continued reading the hospital discharge summary of my new admission. In the periphery of my visual field I saw the young man starting to sort through the items on his cart.

Suddenly he made the same unusual sound, kinked his head and snorted twice again before picking up a pile of clean towels.

Tourette’s syndrome, I thought to myself. Naturally, people must mistake his verbal tics for sneezes all the time and say “Bless you”.

I remembered the day I made that diagnosis for the first time.

It was a bitterly cold Tuesday morning in early December. I was doing a rural rotation six months into my residency, back in my hometown in Sweden. One of my assignments was to hold a weekly clinic for the inmates at a remote prison in a wind-battered coastal town twenty miles from our hospital.

Five miles into my commute the heater in my second-hand Volvo wagon was still blowing cold air, and the base model didn’t come with heated seats. Shivering, I turned the radio on for some distraction from the cold. Just then, the announcer came on the air and said that John Lennon had been shot.

I drove the remaining fifteen miles in a daze, unaware of the temperature or the scenery. I walked up the stairs to the prison clinic and settled into the sparse consultation room. Through the surprisingly thin walls I could hear the clinic nurse escort my first patient of the morning down the hall and into the adjoining exam room.

My daily schedule listed each patient’s name, birth date and chief complaint. As I glanced down the list I heard strange sounds coming from the exam room. By now the inmate was alone in the room – the nurse’s clogs had echoed down the corridor moments before.

Through the wall to my right I heard muttering and a series of coughs and snorts, each punctuated by a sudden, unintelligible monosyllabic outburst.

I began to worry. I was about to enter the room with this individual, and I didn’t know how safe that might be. Was this a violent, uncontrollable person I was hearing, tormented by horrific hallucinations and delusions, likely to snap at any moment? I looked at the patient roster, where his chief complaint was listed as “tics”, which I knew very little about.

I looked around the office. There were only two books on the blond government issue office desk – a Swedish drug reference and the Merck manual, in English.

I searched the index of the Merck Manual and hurried to the section about tics. There, I quickly found exactly what I was hearing through the wall to my right: Gilles de la Tourette Syndrome. I vaguely remembered hearing something about it in medical school, but I had never seen a case of it, and in 1980 there wasn’t the public awareness of this condition that there is today.

Armed with my newly found knowledge about the condition and its treatment, I entered the room, facing only my fear of getting hurt.

The young man seemed gentle and soft-spoken. He greeted me politely and I introduced myself. He told me he had these tics that nobody seemed able to help him with. Suddenly he snorted, kinked his neck and swore under his breath.

“I know what you’ve got”, I said. “I think I can help you.”

“Really?” he said and smiled with tears in his eyes.

1 Response to “Snap Diagnosis”

  1. 1 DocJock February 10, 2010 at 1:11 pm

    The Merck Manual, what a great boon to us physicians! Cheap and as up to date as possible in a textbook. I used it first when I worked in Canada, and still use it here in the UK, where many doctors haven’t heard of it.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Bookmark and Share


contact @

RSS A Country Doctor Reads:

  • More on Bribing Doctors
    The going rate for physician bribery seems to be around $100 per act. In Great Britain it is slightly less, about $88, or £55. In one recent American case, I was offered $100 for putting a hypotensive diabetic patient of mine on an ACE inhibitor (“Incentive, Bribe or Kickback?“) Now my British fellow GPs stand […]
  • Celiac Disease and the Gut-Brain Axis
    Gluten free diets have become somewhat of a fad lately, and many people say that they are not offering any health benefits for most people. But, given the wide range of symptoms and conditions that seem to be associated with celiac disease, it makes you wonder. I had been aware of the physical symptoms claimed […]
  • Ebola and the EMR
    When I heard about the Ebola case in Texas, I was impressed that the doctor made the diagnosis. But according to The Healthcare Blog, the diagnosis was missed and the patient was sent home. Two days later a family member called the CDC and was told to bring the patient back to the ER. The […]
  • Three Little Words
    Newly minted physician Pranay Sinha, opening up about early professional doubts, writes about the comfort a senior colleague’s three words gave: “Dude, me too!” “We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at […]
© A Country Doctor Writes 2008-2014. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.