When you feel sick, the cause is usually a common problem. But sometimes it is not. | Expert Opinion

Physicians live by the rule that everyday symptoms, from back pain to flu-like fever and chills, usually have straightforward diagnoses. But I’ve recently seen a few cases that required thinking outside the box.

Lower back pain is one of the most common symptoms that we encounter in primary care. Fortunately, it is most often caused by benign conditions like muscle or ligament strains or nerve impingements that improve with supportive measures, such as heat, anti-inflammatory medicine, and exercise.

However, this was not the case for one of my patients in February. Her mid- and lower-back pain was unrelenting. She was seen initially in our office, and then visited Urgent Care twice. There, she was reassured that her X-rays were normal and the back strain would gradually improve. Weeks later, she came back to my office and told me, “Something is not right. I think I need an MRI.” She also was worried about appearing to seek strong pain medicines for inappropriate use.

By now, she had been suffering with back pain for over a month, and it was interfering with her work and daily life. She had no neurological abnormalities, which is the usual prompt for spinal MRI imaging. Had I seen her at her initial presentation, I would have likely given the same advice that other clinicians had. At this point though, she was advocating strongly for herself, and my perspective was different. I had never seen her in such discomfort, and she had a strong instinct that something was amiss. I ordered an MRI, which showed a large mass encasing her spine. This most certainly was the cause of her pain. She was referred for urgent surgical evaluation.

Her experience forced me to reconsider an adage that primary care physicians typically live by: “what is common is common.” Like all heuristics or thinking shortcuts, though, we know this can lead us astray if too heavily relied upon. Patients should also keep this in mind when feeling unwell.

Of course, not every symptom or minor illness requires an urgent visit to the doctor or extensive testing. Common symptoms like cough, diarrhea, and joint pain do not usually require doctors’ visits, so long as patients start feeling well with a few days of rest and possibly the use of over-the-counter medications. Yet when things just do not seem to be resolving as you would expect, or if your symptoms feel unusual for you, a primary care appointment makes sense.

In my practice, I have seen other unusual cases from time to time. Last summer, one of my patients developed fever and chills when he returned from his Cape Cod beach vacation. He visited walk-in clinics and received treatment for what seemed like a typical viral infection, but something did not seem quite right.

When he came to our office, he had been ill for almost two weeks with continued fevers, headache, and fatigue. His blood count showed he was anemic. I ordered blood work, and a laboratory microscopic examination revealed that he had Babesiosis, a tick-borne illness endemic to New England. He got better after starting treatment with antibiotics.

More recently there has been a surge in cases of Dengue fever, a mosquito-borne viral illness that can be severe. It is circulating in Puerto Rico, the Caribbean, and Latin America. As clinicians, we must keep our antennae up when patients who have traveled to these areas seek medical attention for fever, muscle aches, rash, or intestinal discomfort – all symptoms which could easily be mistaken for a more common viral illness.

Cases of measles, another disease that we do not routinely see, are also on the rise. The CDC reports that through mid-April, 121 U.S. cases of measles were reported, which is double the total U.S number for all of 2023.

As a patient, be sure that you feel heard and understood at your visit, and that your level of concern is acknowledged. Most Urgent Care clinicians are capable and convenient, but more unusual worries are often best addressed by a primary care team who know you well. And you should know how your doctor’s office handles urgent care needs, as many offices keep a few appointments available for same or next-day care.

Now and then, I will see patients who have suffered for too long before coming to me for care. The most distressing thing they can say is, “I did not want to bother you with something that seemed minor.” I am sure that many of my primary-care colleagues would agree with my advice: Symptoms causing you to feel heightened worry or concern are a good reason to schedule a visit, no matter what the cause turns out to be.

Jeffrey Millstein is an internist and regional medical director for Penn Primary Care.