Pivot and Cluster: An Exercise 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...
KEY WORDSclinical 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.