Clinical Review Lesson of the week

Danger of stereotyping in suspected osteomalaciaCommentary: Stereotyping may delay proper and systematic investigation

BMJ 2001; 323 doi: (Published 21 July 2001) Cite this as: BMJ 2001;323:149

Clinical findings, not ethnic origin, should drive the diagnostic evaluation for suspected osteomalacia

Danger of stereotyping in suspected osteomalacia

  1. Sarah Sheikh, medical studenta,
  2. Ken Williamson, general practitionerb,
  3. Karen Kearley, general practitionerb,
  4. Sophie Bassindale, general practitionerb,
  5. Tim Lancaster (, clinical reader in general practicec
  1. a Corpus Christi College, Oxford OX1 4JF
  2. b Jericho Health Centre, Oxford OX2 6NW
  3. c Department of Primary Health Care, Institute of Health Sciences, Oxford OX3 7LF
  4. Department of Primary Care and General Practice, Medical School, Birmingham B15 2TT
  1. Correspondence to: T Lancaster
  • Accepted 25 April 2001

Clinical findings, not ethnic origin, should drive the diagnostic evaluation for suspected osteomalacia

Clinicians frequently encourage medical students to recognise typical case vignettes (the travelling salesman with sexually transmitted disease, the New Forest hiker with Lyme disease). Pattern recognition is a widely used diagnostic strategy, but its distinction from stereotyping is not always clear cut. We report, from the perspective of general practice, on two patients in whom spurious pattern recognition led to delay in reaching the correct diagnosis.

Case reports

Case 1

A 21 year old English woman, whose parents had emigrated from Pakistan, presented to an accident and emergency department with fatigue and a painful, swollen leg. A venogram was negative. Investigations showed iron deficiency anaemia (haemoglobin 87 g/l, mean cell volume 69 fl), and she was treated with ferrous sulphate. She continued to have pains in the wrist and knee. She was not a vegetarian and ate a balanced diet that included fewer than three pieces of unleavened bread a week. She worked full time outside the home and wore dress that did not shade her face or always cover her arms. Serum levels of calcium (2.38 mmol/l), phosphate (0.91 mmol/l), and alkaline phosphatase (160 IU/l) were in the normal range, but a 25-hydroxycholecalciferol level was 6 µg/l (reference range 7-50). At a hospital outpatient clinic “Asian osteomalacia” was diagnosed. She was discharged to the Jericho Health Centre in Oxford with the recommendation to prescribe ergocalciferol and calcium.

Her pains improved, but she continued to complain of fatigue and developed a new problem of frequent loose stools. She was referred to a gastroenterologist, and a duodenal biopsy showed partial villous atrophy, consistent with coeliac disease.

Case 2

A 67 year old widow had emigrated from Pakistan to England 13 years …

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