Title: When Symptoms Mislead: “Similar” Diagnoses in Primary and Urgent Care

By Janet Tamaren, MD

In both rural and urban environments, primary and urgent care practitioners frequently face a variety of clinical scenarios. Most are standard cases — urinary tract infections, sinusitis, influenza, and management of chronic conditions. With time, these situations become instantly recognizable, allowing for prompt treatment. But what occurs when the clinical indicators do not match expectations? That is when the task becomes both demanding and rewarding.

Throughout my two decades as a family physician in rural Kentucky and subsequently in urgent care centers (UTCs) in Denver, I met numerous patients who entered with clear symptoms and easily diagnoseable conditions. Yet, a few stood out — not due to complexity or drama, but because they challenged my initial diagnostic conclusions. I refer to these patients as “Look-alikes” — individuals whose symptoms resembled a common ailment, but whose actual diagnosis ended up being something distinctly different.

Here are two enlightening case studies from my years of practice. They serve as a reminder that even seasoned clinicians can be misled by medicine’s clinical chameleons — and that collaboration, curiosity, and humility are crucial instruments in any diagnostic arsenal.

Case 1: An Erroneous Diagnosis of Hyperlipidemia

A 45-year-old Hispanic man visited the clinic with striking yellow nodules on his arms and hands. His English was limited, but with the help of a staff translator, I discovered that these nodules had emerged over the previous month. Having encountered a similar case years ago — lipid deposits resulting from hypertriglyceridemia — I quickly considered hyperlipidemia.

Trusting my clinical instincts, I requested a lipid panel and initiated treatment with atorvastatin (Lipitor), which is commonly prescribed for suspected hyperlipidemia. He was self-paying and preferred to start treatment right away rather than wait for lab results.

Upon his return two weeks later, the situation had not improved — the nodules had intensified. Even more perplexing, his lipid panel returned completely normal results. My initial confidence started to wane. Confounded and slightly humbled, I discussed the case with a well-respected colleague — an experienced octogenarian physician.

His concise but wise response: “Gout. They resemble tophi.” He advised testing serum uric acid levels and initiating allopurinol.

He was correct. The patient’s uric acid was markedly elevated, correlating with the classic presentation of tophaceous gout — a chronic form of the disease where urate crystals accumulate in the skin and joints. With appropriate treatment, the nodules began to diminish, and the patient improved.

Lesson learned: not every yellow nodule is related to lipids. Gout can convincingly disguise itself.

Case 2: Ketoacidosis Without Diabetes

The second case featured a Caucasian woman in her early fifties, who arrived at our urgent care center exhibiting significant distress. She was lying on the exam table, feeling nauseated, complaining of dizziness, and had been vomiting. Notably, she had a history of gastric bypass surgery, which intrigued me. Crucially, she reported no history of diabetes.

We tested her urine, and the urinalysis revealed substantial ketonuria — yet, intriguingly, her glucose levels were normal, both in the urine and via a fingerstick test. In medical school, I had learned to associate ketonuria with diabetic ketoacidosis (DKA), typically accompanied by elevated blood sugar. However, here was a conundrum: ketoacidosis without hyperglycemia.

Determined but puzzled, I stepped out to consult my reliable reference at the time — “Current Medical Diagnosis and Treatment,” a trusted resource before the era of instant online information.

In it, I found a clue: Alcoholic ketoacidosis (AKA), a condition seen in individuals with inadequate nutrition and frequent alcohol consumption, particularly those who have had surgical procedures like gastric bypass that affect nutrient absorption.

Returning to the patient, I tactfully probed for details about alcohol use. She confessed to consuming one to two glasses of whiskey daily, despite her surgeon’s post-operative instructions to completely avoid alcohol.

With this new perspective, we commenced IV fluids to stabilize her and admitted her briefly for monitoring and correction of her metabolic imbalance. We also provided education on alcohol-related dangers.

Here, the “aha” moment was profoundly gratifying. A textbook DKA look-alike revealed itself to be a metabolic complication stemming from alcohol usage and malnutrition.

Reflections on Diagnostic Challenges

Cases such as these offer more than mere intellectual engagement. They remind us that while clinical pattern recognition is incredibly valuable, it can also lead to errors. Bias, overconfidence in previous experiences, and linguistic or cultural obstacles can all distort decision-making. This is why maintaining diagnostic adaptability and seeking second opinions, particularly from seasoned colleagues, is essential.