CASE: patient with chest pain

40-year-old Male patient with a 3 day history of chest pain. He also describes epigastric pain.

He has raised glucose in the urine with +1 Ketones.

He appears to be sweating.

ECG was normal.

Could he have pancreatitis?

Could he have myocarditis or pericardititis?

What is Hickam's dictum?

What is Saint's Triad?

What Three Wise Men have to say about diagnosisNavin Mani and colleagues examine Occam’s razor, Hickam’s dictum, and Crabtree’s bludgeon Most clinicians will be familiar with Occam’s razor, a guiding principle that is interpreted as “the simplest explanation is to be preferred.” In relation to medical diagnosis this is taken to mean that when a patient has multiple symptoms and signs, a single diagnosis should be sought that accounts for all the clinical features rather than attributing a different diagnosis to each. To what extent should we rely on Occam’s wisdom? All clinicians can recall patients who have not conformed to this principle, and over reliance on it has the potential for misdiagnosis. Accurate diagnosis underpins good clinical practice; figures suggest that rates of diagnostic errors in the emergency department setting are as high as 10-15%1 and that misdiagnosis is responsible for around 10% of adverse events in hospitals.2 With this in mind, we present examples for and against the use of Occam’s razor from our area of interest: head and neck oncology, the management of which provides a good template to study these diagnostic dilemmas. Most patients undergo imaging of distant sites at diagnosis, and spread to the regional lymph nodes usually occurs in a predictable pattern before distant metastases. We also examine the views of other “wise men” who have proposed principles that caution against over reliance on Occam. A 60 year old female smoker presented with haemoptysis. Chest radiography showed an opacity in the middle lobe of her right lung. She underwent lobectomy. Histology showed adenocarcinoma with clear resection margins (stage T2 N0 M0). No adjuvant therapy was given. One year later she presented with a left tonsillar mass and left cervical lympadenopathy (fig 1⇓). Biopsy of the left tonsil was reported as adenocarcinoma (stage T2 N2b M0) with similar histological features …

Occam's Razor

Latin phrase entia non sunt multiplicanda praeter necessitate,

“entities must not be multiplied beyond necessity.

When a patient with multiple symptoms is being investigated the clinician should seek a single diagnosis rather than diagnosing two or more unrelated ones.

This is sometimes referred to as diagnostic parsimony.

Hickam: “patients can have as many diseases as they damn well please”

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