History is the basic of basis of diagnosis

History is the basic of basis of diagnosis 

One fine morning I was in OPD with full delight in my face. A woman about 40 yrs of age came to OPD room and sat on the chair.  She spoke with an  unintelligible voice. I thought she had come for the change in voice. But it had been the same since childhood.  

The complaints were nonspecific. She had feeling of being unwell and malaise since long time.  I couldn't find any abnormality in examination except for the bluish black discoloration in the palms of hands. I was curious about the very discoloration and asked a few questions. She had such discoloration since long time. I couldn't make out more from her spoken labguage.  Her voice was not intelligible. I was in a rush to screen the clinical symptoms and signs because there was a long queue of patients.  

I ordered a few specific  investigations.  Since I couldn't understand her voice, I didn't want to miss the case. The investigation included ANA as well. However, it came negative. 

All the reports came normal. The only abnormality was her thyroid function test, which showed hypothyroidism. But, it didn't explain her symptoms. 

I recommended a friend of mine to her  for the follow up in about a month. She had no improvement in symptoms. 
When she visited him, he found the discoloration of hands. That time she had a friend with her. It made the conversation easier and he came to know that she had bluish discoloration of digits on exposure to cold.  So he ordered the test for ANA by Immunofluroscence technique. As expected, it came positive. 

Morale: Clinical features matter above the lab results. 

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