Journal of General Internal Medicine

, Volume 33, Issue 2, pp 226–230 | Cite as

Pivot and Cluster: An Exercise in Clinical Reasoning

  • Jori E. May
  • Reaford J. Blackburn
  • Robert M. Centor
  • Gurpreet Dhaliwal
Clinical Practice: Exercises in Clinical Reasoning

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.

  A 68-year-old woman presented to primary care with 1 year of intermittent fever up to 39 °C, nausea, and an unintentional 80-pound weight loss. She also had drenching night sweats multiple times per week.

Sustained fever is generally caused by infectious, malignant, or autoimmune disorders. Initial considerations in this case would include human immunodeficiency virus (HIV), tuberculosis, lymphoma, and hyperthyroidism. Occasionally, autoinflammatory disorders may be responsible. In contrast to autoimmune disorders, which arise from antigen-dependent activation of the adaptive immune system, autoinflammatory disorders are characterized by antigen-independent activation of the innate immune system. Medications can cause fever as...


clinical reasoning urticaria whiteboard pivot and cluster 



This case was presented at the annual meeting of the 2016 Alabama chapter of the American College of Physicians (ACP) and at the 2017 national ACP meeting.

Compliance with Ethical Standards

Conflict of Interest

Drs. May, Blackburn, and Centor declare that they have no conflict of interest. Dr. Dhaliwal reports receiving honoraria from ISMIE Mutual Insurance Company and Physicians’ Reciprocal Insurers.


  1. 1.
    Shimizu T, Tokuda Y. Pivot and cluster strategy: a preventive measure against diagnostic errors. Int J Gen Med. 2012;5:917–21.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Rajabally YA. Neuropathy and paraproteins: review of a complex association. Eur J Neurol. 2011;18(11):1291–8.CrossRefPubMedGoogle Scholar
  3. 3.
    De Koning HD. Schnitzler’s syndrome: lessons from 281 cases. Clin Transl Allergy. 2014;4:41.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Lebbe C, Rybojad M, Klein F, et al. Schnitzler’s syndrome associated with sensorimotor neuropathy. J Am Acad Dermatol. 1994;30(2 Pt 2):316-8.CrossRefPubMedGoogle Scholar
  5. 5.
    Krause K, Grattan CE, Bindslev-Jensen C, et al. How not to miss autoinflammatory diseases masquerading as urticaria. Allergy. 2012;67(12):1465-74.PubMedGoogle Scholar
  6. 6.
    Simon A, Asli B, Braun-Falco M, et al. Schnitzler’s syndrome: diagnosis, treatment, and follow-up. Allergy. 2013;68(5):562-8.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Jori E. May
    • 1
  • Reaford J. Blackburn
    • 2
  • Robert M. Centor
    • 1
    • 3
  • Gurpreet Dhaliwal
    • 4
    • 5
  1. 1.Department of Medicine University of Alabama at BirminghamBirminghamUSA
  2. 2.Lake Cumberland Regional HospitalSomersetUSA
  3. 3.Medical ServicesBirmingham VA Medical CenterBirminghamUSA
  4. 4.Department of MedicineUniversity of California San FranciscoSan FranciscoUSA
  5. 5.Medical ServiceSan Francisco VA Medical CenterSan FranciscoUSA

Personalised recommendations