The Zebra in the Room

A student’s experience sheds light on the root cause of medical misdiagnosis.

“By a show of hands, how many people in this room have been sick with the common cold or flu?” Scott Fiorini asked the audience at the second annual Hawk Talks, held in April. “Congratulations, you guys have all been diagnosed as human beings.”

Fashioned after TED Talks, Hawk Talks, held during Monmouth’s Student Scholarship Week, gives students five minutes to share what they learned during a recent academic experience. Fiorini, a graduate student in the Physician Assistant Program, kicked off this year’s event with a personal experience that sheds light on a growing issue in healthcare: misdiagnosis, which affects approximately 12 million Americans every year.

While the cold or flu is a common diagnosis that is typically easily treatable, Fiorini explained that issues arise when more serious health problems are disguised by symptoms that get mistaken for common ailments.

“A zebra is a term that we refer to as a rare disease—it comes from the saying, ‘When you hear hoof beats, think horses, not zebras,’” Fiorini said. “However, diseases do not read the textbook, and sometimes zebras present as the common cold.”

Last summer, Fiorini was on shift for his internal medicine rotation at a hospital in North Jersey, when 55-year-old Brandon came to the ER complaining he felt sick. Brandon told the staff he had recently been released from jail, had been eating poorly, and had failed to take his diabetes medication for nearly two months.

Tests showed his blood sugar levels were nine times higher than normal. The team brought his levels down within normal range, and the treatment was considered a success. But when Fiorini went to check on the patient, he noticed something strange.

“He couldn’t answer me without coughing, so I said, ‘OK, let’s think this out,” Fiorini recalled. “We have a diabetic, but he’s coughing. … Diabetes does not make people cough. So, I said to myself, ‘OK, let’s step back and let me conduct a full history and physical exam.”

As Fiorini spoke with Brandon, he learned the patient had developed the cough in jail, that he had it for nearly seven months, that it lasted nearly all day, and that he often coughed up phlegm that was red.

That stopped Fiorini in his tracks. It meant Brandon had been coughing up blood, indicating a potentially more serious diagnosis: tuberculosis, an infectious disease that affects the lungs. Sure enough, Brandon’s tuberculosis test came back positive.

“Brandon had been in the ER for eight hours at that point, exposing family, friends, health-care providers, and [other] patients,” Fiorini said. “So, where was the communication lost? The answer is on both sides.”

Fiorini said Brandon should have made it clear to healthcare providers that he was struggling with a severe cough for so long, and, as the team later found out, that he was also suffering from severe night sweats. At the same time, Fiorini said the medical team should have asked more questions instead of relying on an initial diagnosis that focused on the main issue of getting Brandon’s sugar levels down.

The episode sheds light on how important it is for health-care providers to ask questions and for patients to share as much information as possible, Fiorini said.

“When you’re sick, give us a look into your life for the last couple of weeks,” Fiorini said. “If something doesn’t feel right, bring it up. If something doesn’t look right, show us. And if you don’t know, ask.”

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