The Art of Differential Diagnosis in a Super-Hero World

June 3rd, 2008

Filed under: Comics, Medicine

The Differential Diagnosis is one of the key aspects of good medicine. To make a differential diagnosis, the physician takes the patient’s chief complaint and comes up with a list of the possible causes of that problem. This list is then narrowed down by considering the patient’s other symptoms, physical exam findings and lab and radiology results. Eventually, the correct diagnosis is uncovered.

When House and his team try to determine what their patient has by looking at the whiteboard with all the symptoms listed, they are performing a differential diagnosis (a bastardized version actually, since they seem to focus on rare conditions — “zebras” — rather than more likely causes).

For a real world example, if a patient presents complaining of a sore throat, there are at least fifty to sixty possible diagnoses, the most common of which (in my practice, anyway) would be viral infection, allergies, Strep throat, or sinusitis. If the patient also complains of a fever, this makes it likely to be an infection. A cough would make Strep less likely and allergies and sinusitis more likely. Headaches are common with Strep and sinusitis. Chronic symptoms are more likely to be allergies. Symptoms presenting in the dead of winter are more likely infectious. Taking all the symptoms into account, along with a good patient history and a thorough physical exam, would allow the physician to come up with the likely cause of the sore throat (this time of year in the Midwest, probably allergies).

Differential diagnosis can be very challenging in the real world, but imagine how incredibly difficult it must be in a fantasy world where literally anything is possible. Take one of my favorite examples: a nosebleed. In the real world, this probably represents an irritated nose (from an infection or allergies), trauma (including “finger trauma”), or a bleeding problem. In the super-hero world, you also need to add psychic powers, magic powers, possession, and alien abduction, just to name a few. How do you test for those?

Another example comes from this week’s JSA Classified. Wildcat visits one of his old-time boxing opponents and finds him slumped in a wheelchair, virtually comatose. The family tells him that this happened suddenly, on a recent trip to New York. If this were my patient, I would be worried about a stroke, aneurysm, encephalitis, or dementia pugilistica. But not Wildcat, he immediately deduces that his friend was the victim of memory draining villains. That would never cross my mind, but it was the first thing he thought of.

As boring and conventional as it may sometimes be, I think I prefer the practice of medicine in the real world.

Case Study #1: The patient is 13 year old girl who is very bright and generally does extremely well academically. For the past week she has been sent home repeatedly from school with bad headaches. There is no prior history of headaches. There are no associated symptoms. The headaches resolve with rest in a dark room; over-the-counter medication offers little relief. Of note, there is increased stress at home with her parents frequently discussing divorce.
This patient has:
A. Migraine headaches
B. Tension headaches
C. Chronic Daily Headaches
D. Somatization related to stress avoidance
E. The emergence of a mutant power

Click here for the ANSWER
Case Study #2: The patient is a fifty year-old man who complains of several minutes of “blacking out.” He does not recall fainting or falling, but there are several minutes that he cannot remember. He denies any recent head trauma. He haa a high stress job and smokes at least 2 packs of cigarettes per day. He has a known history of cardiovascular disease including a severe heart attack within the past few years.
The most likely cause of this patient’s complaint is:
A. Transient Ischemic Attack (a “mini-stroke”)
B. Heart arrhythmia
C. Vasovagal response (a “fainting spell”)
D. Brief amnesia related to psychological stress
E. Possession by a ghost

Click here for the ANSWER
Tags:

8 Responses to “ The Art of Differential Diagnosis in a Super-Hero World ”

  1. arkonbey
    June 4th, 2008 at 9:34 am

    nothing to say except that it made me laugh. That short post summed up a lot of the fun of the comic book world.

  2. ScienceGiant
    June 4th, 2008 at 10:23 am

    Actually, Scott’s post just narrows the focus on a wide swath of science fiction & fantasy.

    For instance, I recall in an episode of Star Trek where the characters are talking about all the possible causes for the trouble they are encounters, and among the things ticked off on what could go wrong are alien encounter, parallel universe, and time travelling.

    But I suppose we could go back to Bram Stroker to blame for this. When examing why Lucy is weakening, Van Helsing realizes she must the victim of… a vampire!

  3. fluffy
    June 4th, 2008 at 12:40 pm

    So, which would be the correct responses in the real world? My suspicions would be migraine and a transient ischemia attack, but I am of course not a doctor (but I do go through periods of severe migraine and that sounds very familiar to me, and on the second one I think you can rule out B, C and D because D seems unlikely to even be brought up by a patient and B and C would involve several periods of actual fainting which he’d remember, right?).

  4. Scott
    June 4th, 2008 at 1:06 pm
    Official Comment

    fluffy,

    For the real world:

    In my experience, D is the most common cause in situations like Case #1, but A would be fairly common as well.

    For Case #2, I would be most concerned about A, though I would probably want to work-up B too.

  5. Mark Temporis
    June 4th, 2008 at 8:53 pm

    I highly suggest you make these a regular part of your blog. Got them both, BTW. You might want to mix things up by having two paranormal choices.

  6. Shibia
    June 5th, 2008 at 3:24 pm

    IIRC, Kitty Pride suffered during all her early teens from migraines, and not only just before her powers emerged. It was linked to her mutant power, but not a simple symptom. Strangely, when she joined Excalibur (and was physically a grown-up) no more migraine. Could it simply be a sympton of teen hormonal confusion ?

    (sorry for the syntax, English is not my first language)

  7. Jason Barnett
    June 5th, 2008 at 6:38 pm

    When Kitty joined Excalibur she’d suffered a massive physical injury that altered her from solid girl who can become non-solid, to non-solid who can become solid.

  8. GW Crawford
    June 12th, 2008 at 11:17 am

    Always best to stake first, diagnose later…

    Come on, back me up on this!

Leave a Reply

« Monday PSA: Prescription Against Accidents Energy to Get There! »