onthewebonthewebonthewebonthewebonthewebonthewebonthewebonthewebonthewebDiagnosis ChallengePhysicians are often called upon to diagnose a wide range of symptoms andconditions. In this section, we offer our readers the chance to follow a physicianthrough the diagnosis process. What diagnosis would you make?The Patient with theCan’t-Stop CoughGary* was exhausted. He could barely keep his eyes on theroad. Not even the strongest cup of coffee could perk himup. Several times during the drive to work he caught himselfveering off the road, jerking the wheel in the other direction toget his car back on the highway.For weeks he had been suffering severe and repetitivecoughing fits. His sleep was constantly being interrupted byspasms of coughing. Midnight. 2 a.m. 4 a.m. He had hackingbouts during the day, too, often ducking out of meetings toavoid the annoyed stares of his boss and co-workers.Gary assumed it was nothing more than a cold, writing offhis symptoms as a typical winter-weather bug. But after threeweeks of excusing himself from the table at restaurants, suppressingcoughing fits in public, and waking up with chokingepisodes so violent he sometimes gagged, he decided a visitto the doctor was in order.The Office VisitCleveland Clinic physician Camille Sabella,M.D., listened to Gary explain his symptoms:several weeks of violent coughing, sometimesto the point of vomiting, and feelings of dehydration.Gary didn’t experience sinus-relatedproblems - no stuffy head or trouble breathing- other than when he couldn’t catch hisCamille Sabella, M.D.breath during a coughing fit.Gary has no history of asthma or respiratory infections,and he has no fever or abnormal temperature. Dr. Sabellainquired about Gary’s lifestyle and discovered that he isnot a smoker and maintains a fairly healthy diet, avoidinglate-night dinners or excessive alcohol consumption. Gary ismarried, without children, and his wife has not developed acough or similar symptoms. A thorough physical examinationof Gary was completely normal.Based on the described symptoms, Dr. Sabella formed afew theories about what Gary’s condition might be:Bronchitis – Gary’s cough alerted Dr. Sabella to the possibilityof this common breathing condition in which the bronchialtree inside the lungs becomes infected by a virus. Symptomsof bronchitis come on quickly and can persist for weeks.Common Cold – Winter weather and an office atmosphereharbor a slew of common cold viruses. Gary might havepicked up a virus from a co-worker. Fatigue and stress cancause colds to linger.Gastroesophageal Reflux – Characterized by a backwash ofstomach contents and acid into the airway, symptoms of thiscondition include coughing, gagging and vomiting. Also, it iscommon for these symptoms to occur at night.Pertussis (Whooping Cough) – Pertussis is a highly contagiousbacterial disease that affects the respiratory system. It producesspasms of coughing that may end in a high-pitched, deep inhalationin children, although the “whoop” is rare in adults.Asthma – With asthma, inflammation of the airways causesairflow into and out of the lungs to be restricted, producingthe characteristic wheezing sound. Mucus production also isincreased.As a next step, Dr. Sabella ordered a test for whoopingcough bacteria from the back of Gary’s nose to culture in thelaboratory. In addition, he ordered a chest X-ray.Dr. Sabella then continued with his assessment. After acareful history and physical examination, Dr. Sabella determinedthat Gary did not have bronchitis. Although bronchitissymptoms can last for a couple of weeks, Gary’s symptomswere too severe and prolonged for bronchitis.A cold was the least likely conclusion. Gary didn’t displayrelated complications, such as a stuffy or runny nose, sore throator fever. Also, colds generally run their course in two weeks.Because Gary is careful not to eat late or consume excessiveamounts of alcohol, the likelihood of gastroesophagealreflux was minimal. Reflux is common following meals, andGary experiences coughing symptoms most of the time.In addition, asthma seemed unlikely since Gary has nopast history of asthma, no history of wheezing or shortness ofbreath, and his physical examination was normal.Gary’s chest X-ray was normal and the nasal culture cameback negative for the whooping cough bacteria, meaning Dr.Sabella did not find anything in the culture that alerted himto pertussis.So, what could be the cause of Gary’s condition?For Dr. Sabella’s diagnosis, go to our Web site atwww.clevelandclinic.org/<strong>clevelandclinicmagazine</strong>You can also send us an email at<strong>clevelandclinicmagazine</strong>@ccf.org and we will emailyou the diagnosis.*The patient and history presented in “Diagnosis Challenge” are fictional.8 cleveland clinic magazine
onthewebonthewebonthewebonthewebonthewebonthewebonthewebonthewebonthewebLiving HealthyThe Unhealthy TanIn the United States, the percentage of people who developmelanoma, a form of skin cancer caused by sun exposure,has more than doubled in the past 30 years. Each year, morethan 50,000 new cases are diagnosed.While those numbers are disturbing, another alarm issounding: young people, without years of sunlight exposurelike the majority of skin cancer sufferers, are increasinglybeing diagnosed with melanoma.“Although it is still fairly rare in children, I’ve seen studieswhere cases of melanoma are found in children as young asfour years old,” says Julian Kim, M.D., a staff physician whospecializes in surgical oncology. “The concern now is thatwe are seeing people in their late teens and early 20s beingdiagnosed more and more with melanoma.”In this day and age, the mental connection between tannedskin and good health still prevails. This concept has drivenpeople to seek a sun-kissed look, whether it’s through sweatingon the beach, using artificial tanners, or “fake baking”- spending10 or 20 minutes in a tanning bed.“Although the cause of this trend of more young peoplewith melanoma is not yet known, tanning booths are probablya contributing factor,” says Dr. Kim. The major concernwith tanning beds is the extremely intense, damaging ultra-Microscopic image of skin cancer.violet (UV) rays. Tanning beds can provide hours of sunlightin minutes, and that is highly dangerous for a person’s skin,especially when the practice begins at younger ages.Some people use tanning beds to get a “base tan” so theydon’t burn on sun-filled vacations. However, a person doesn’tneed to have excessive sunlight to develop melanoma, Dr.Kim warns. “I have diagnosed patients with melanoma whohave had very brief exposure to sunlight and may have onlyvisited a tanning bed once or twice.”Unfortunately, many young people still sunbathe and visittanning beds regularly. Dr. Kim believes this is because “theconcept of cancer hasn’t sunk in to young people yet. I haveto tell college students they have a deadly disease, and theylook at me like it’s impossible.”With all the pressure to have that sun-loving look, what dodoctors tell their young patients to encourage them to avoidoverexposure to the sun?“I tell them that the damage the sun can do to their skin isirreparable, even if it doesn’t show up until years later,” saysDr. Kim. “You only have one set of skin, and it has to last youyour whole life.”For more information about melanoma risks and safeguards, go toour Web site at www.clevelandclinic.org/<strong>clevelandclinicmagazine</strong>Readers’ SurveyReaders’ PollInformation From YouMakes the Informationin Here BetterWe want to hear what you think aboutCleveland Clinic Magazine. Please take a fewminutes to go online and fill out our survey.As a special thanks, we’ll send you our exclusiveCleveland Clinic Magazine 7-day pillbox.Go to www.clevelandclinic.org/<strong>clevelandclinicmagazine</strong>The Gift of Life:Organ DonationOn our Web site, readers are invited to share theiropinions about subjects from the magazine.In the “Changing Transplantation” story (this issue, page16), we talk about innovations on several medical fronts thatare changing the way we approach organ donations andtransplantation. Tell us what you think in our next Readers’Poll “The Gift of Life: Organ Donation” atwww.clevelandclinic.org/<strong>clevelandclinicmagazine</strong>You can also visit our Web site to find out what readershad to say in our last poll, “A New Kind of Office Visit:Shared Medical Appointments.”www.clevelandclinic.org 9