Run the List Podcast Episode Summary

Episode: When Illness Scripts Fail: A Mystery Case

Date: September 30, 2025
Hosts: Walker Redd, Emily Gutowski, Navin Kumar, Joyce Zhou, Blake Smith
Guest: Dr. Mitchell Cherup (Professor of Medicine, NYU Langone)

Overview:

This episode departs from the usual format to explore a compelling outpatient mystery case presented by Dr. Mitchell Cherup. The discussion centers on the limitations of classic "illness scripts"—the mental models clinicians use for diagnosing diseases—especially when real patients present atypically. Listeners are taken through the methodical clinical reasoning process, highlighting the importance of physical exams, the pitfalls of cognitive shortcuts, and nuances in pulmonary embolism (PE) presentations, particularly in young, healthy patients.

Key Discussion Points & Insights

The Challenge of Illness Scripts in Real-Life Practice

• Dr. Cherup describes how illness scripts are invaluable but may fall short when key features do not line up with textbook scenarios.
  • "Illness scripts vary, and sometimes they vary so much that they bear very little relationship to the original illness script we had thought about." (02:10)

The Mystery Case Unfolds

Patient Background and Presentation

• Patient: 43-year-old healthy male, experienced sudden right back and shoulder pain two days after strenuous exercise (running and weightlifting) (03:20).
• Tried NSAIDs, acetaminophen, and codeine—pain persisted; exacerbated by deep breaths and lying on the right; no fever, cough, or shortness of breath.

Initial Differential Diagnosis

• Dr. Cherup:
  • Considered musculoskeletal injury or rib fracture based on history and absence of right-sided kidney stones.
  • "I thought he had muscular skeletal pain... muscle strain or perhaps he had a rib fracture from the exercise." (05:49)

Exam Findings and Early Clues

• Vitals: All normal (Pulse 60, BP 115/80, RR and O2 saturation normal). (06:16)
• Physical Exam: Dullness to percussion and decreased breath sounds at right lung base; right-sided CVA tenderness; everything else normal.
  • "I noticed that there was slight dullness, dullness to percussion, and decreased breath sounds at the right base... That was a bit of a surprise to me." (06:34)
• Noted importance of thorough physical exams in picking up subtle but critical clues.

Diagnostic Workup in the Office

• EKG: Normal
• Urinalysis: No hematuria
• Chest X-ray: Small right pleural effusion, possible atelectasis or infiltrate; unclear about rib fracture. (08:00)
  • Led Dr. Cherup to consider further imaging despite low classic risk for PE.
• Decision to order CT PE study despite "Wells score 0" or any other risk scale indicating very low risk.
  • "I did know that pleural effusions are relatively common in, in patients with pulmonary emboli. They occur into 20 and 40% of patients who have pulmonary embolic disease." (08:39)

Approaching the Diagnostic Dilemma (Clinical Reasoning)

• Acknowledgment of differences in workup and available resources in outpatient vs. inpatient settings. (09:49)
• Navigating family skepticism (patient’s wife, a PA, was unconvinced about PE risk) and need to justify “out-of-script” decision-making.
  • "I said, but it's also a diagnosis that I really don't want to miss, and I don't think it's a harmful procedure, and it'll give us a lot more information." (10:43)

The Answer Revealed: Pulmonary Embolism

• CT findings: Multiple acute pulmonary emboli in both right and left lower lobe arteries; right lower lobe pulmonary infarct. (10:57)
  • "It showed multiple central filling defects... consistent with acute pulmonary emboli... ground glass opacity... consistent with a pulmonary infarct." (10:57)
• No evidence for lower extremity DVT on Doppler.

Risk factors and final management

• Thrombophilia screen: Factor V Leiden heterozygosity (low-level risk); no other risk factors (e.g., travel, surgery).
• Patient admitted for pain management, started on anticoagulation; long-term anticoagulation recommended.

Teaching Pearls and Clinical Learning Points

How This Case Broke the Mold

• PE in young, healthy individuals: Can present with isolated, severe, pleuritic pain—no dyspnea, no classic risk factors, minimal exam/lab abnormalities.
  • "Young patients who have pulmonary emboli tend to have fewer symptoms of pulmonary embolic disease." (13:45)
• Pleural effusion as a PE clue: Small effusions present in up to 40% of cases.
  • "I will admit I would not have associated pleural effusion with PE." – Host (14:39)
• Physical exam as a guide to further workup; would have missed PE if not for detecting subtle effusion.
  • "If I hadn't picked up that there was a possible pleural effusion, I may have... just given him more analges..." (13:39)

Data on Young Patients with PE

• Up to 60% of young patients with PE lack cardiopulmonary abnormalities or DVTs (twice the rate of older patients).
• 70% of young PE patients are not tachycardic; 80% of older PE patients are tachycardic.
• 20% of young PE patients present with isolated pleuritic chest pain.

The Limits of Algorithms and Need for Clinical Judgment

• The importance of maintaining high index of suspicion and not being wedded to classic illness scripts, especially in atypical groups.
  • "Illness scripts are helpful, but the clinical context in which they occur is helpful." (15:43)
• Reaffirming the art of the physical exam despite technological advancements and reliance on imaging.
  • "You need to be able to do a good physical exam." (16:15)

Notable Quotes & Memorable Moments

• On illness scripts and atypical cases:
  • "Sometimes [illness scripts] vary so much that they bear very little relationship to the original illness script we had thought about." – Dr. Cherup (02:10)
• On physical exam as a diagnostic turning point:
  • "I noticed that there was slight dullness, dullness to percussion, and decreased breath sounds at the right base. ... That was a bit of a surprise to me." – Dr. Cherup (06:34)
• On practical medicine vs. training:
  • "We’re taught to think of horses, not zebras...but you'd better be familiar with all the equines if you want to stop it." – Host (00:17)
• On outpatient diagnostic challenges:
  • "It completely depends on the hospital versus the clinic setting, what resources you have available to you..." – Host (09:49)
• Learning point for trainees:
  • "Never lose the art of the physical exam." – Host (16:18)
  • "Please don't do that." – Dr. Cherup (16:21)

Timestamps for Important Segments

• Opening on illness scripts and their limits: 01:50–03:01
• Case presentation and initial workup: 03:20–06:34
• Physical findings and diagnostic reasoning: 06:34–08:00
• Imaging decisions and justifying further workup: 08:00–10:55
• CT findings and final diagnosis: 10:57–11:40
• Discussion of management and teaching pearls: 11:45–15:43
• Epidemiology and atypical PE presentations in the young: 14:53–15:55
• Final reflections on clinical practice and physical exam: 16:15–16:21

Takeaways for Medical Trainees and Practitioners

• Do not rely solely on textbook illness scripts—context matters.
• Be meticulous with physical exams—small clues can be critical.
• Maintain suspicion for PE even in young, healthy, active people with ‘musculoskeletal’ pain and no classic risk factors—especially if pleural effusion is found.
• Algorithms and scoring systems (e.g., Wells, D-dimer) are guides, not gospel.
• Adapt your approach based on setting and available resources.
• Stay humble, open-minded, and always ready to challenge your own assumptions.

Episode endorsed by Dr. Cherup's reminder:
"Please don't lose the art of the physical exam." (16:21)