I'll never forget one of my endocrinology lecturers in medical school professing about how he had diagnosed the lady in his local fish and chip shop with acromegaly the first day he laid eyes on her, and that every time he went for his cod and chips wrestled with the dilemma as to whether or not he should tell her his diagnosis.
- I'll have the large cod and chips thanks, no peas, by the way, you know that huge nose of yours, the masculine brow and all that facial hair? yeah well, I reckon you've got acromegaly.
- I beg your pardon!? acrowhat? how DARE you!
- Well it was merely an observation madam, that you have been looking increasingly like a man over the years, and I think I know the reason - you've got a pituitary tumour. [nods smugly]
- A what?
- A tumour, in part of your brain, secreting growth hormone. That's why your hands are like spades and your shoe size has increased 10 sizes in the past five years.
- So you're telling me I look like a man and I have a brain tumour??
- Yes it's probably the reason you sweat so much and your skin is so greasy. You need to see an endocrinologist, and it's your lucky day..!
I suspect he probably still hasnt broached the subject. I had a similar dilemma myself the other day when I noticed that the bank clerk sorting out my friend's accounts had stage 3 finger clubbing. He was a young guy, around late 20s, looked fairly healthy. What was I to do? It could be normal for him, or he could have some serious underlying disease. I spent a good 20 minutes staring at this chap's fingers, he must have thought I was rather odd. But what could I do? It didnt seem the time or the place to bring the subject up.
Did I have a duty of care to this guy simply because I am a doctor and my level of knowledge allows me to recognise such a clinical sign as being potentially significant? If I was his GP and he were sat in my consulting room I would have no issue with asking him reams of intimate questions in an attempt to screen for any potential serious disease but with roles reversed, such a course of action seemed most inappropriate.
Perhaps I could have asked how long his fingernails has been like that. My most likely differential was something like cystic fibrosis or crohn's disease, which if he had, he would know about and would probably know his fingers were clubbed. This would then be easy, he could smile knowingly and say "a very long time" and I could smile knowingly and say "I'm a doctor, couldnt help but notice" and leave it at that. The problem would come if he had no idea there was anything wrong with his fingernails, as bringing it up then carried a high risk of either causing offence or inciting great terror, or both.
- How long have your fingernails been like that?
- My fingernails? What's wrong with my fingernails?
- Well, they're clubbed, it could be a sign of serious underlying disease. Or it could be nothing.
- What sort of underlying disease?
- Oh many things, lung cancer, TB, bacterial endocarditis, cirrhosis.. how are your bowels?
- Pardon?
- I said how are your BOWELS? [other bank customers turn round to look]
- They're fine.
- Probably not crohn's disease or ulcerative colitis then. Hmm, you do look a bit syndromic, could be congenital cyanotic heart disease.
Hmm.. probably a good thing I didn't say anything, but I am curious.
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