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Case Reports
. 2018 Feb;33(2):226-230.
doi: 10.1007/s11606-017-4216-6. Epub 2017 Nov 28.

Pivot and Cluster: An Exercise in Clinical Reasoning

Jori E May  1 , Reaford J Blackburn  2 , Robert M Centor  3   4 , Gurpreet Dhaliwal  5   6
Affiliations
Case Reports

Pivot and Cluster: An Exercise in Clinical Reasoning

Jori E May et al. J Gen Intern Med. 2018 Feb.
No abstract available

Keywords: clinical reasoning; pivot and cluster; urticaria; whiteboard.

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Conflict of interest statement

Drs. May, Blackburn, and Centor declare that they have no conflict of interest. Dr. Dhaliwal reports receiving honoraria from ISMIE Mutual Insurance Company and Physicians’ Reciprocal Insurers.

Figures

Figure 1
Figure 1
The urticaria cluster: chronic idiopathic urticaria (CIU) is the pivot diagnosis, while rare conditions such as urticarial vasculitis (UV), mastocytosis (Mc), and Schnitzler’s syndrome (SS) reside at the edge of the cluster.
Figure 2
Figure 2
The interplay between diagnostic clusters guides the diagnostic process. The pivot of the neuropathy cluster is diabetic neuropathy (DN), which is surrounded by vitamin B12 deficiency (B12), paraneoplastic neuropathy (PN), and vasculitic neuropathy (VN). The pivot of the paraproteinemia cluster is multiple myeloma (MM); three cluster components—amyloidosis (Am), Waldenstrom’s macroglobulinemia (WM), and POEMS—also fit within the neuropathy cluster. Schnitzler’s syndrome is the only diagnosis that resides in the overlap between all three clusters and explains the other salient features of the case, listed on the right.
See this image and copyright information in PMC

References

    1. Shimizu T, Tokuda Y. Pivot and cluster strategy: a preventive measure against diagnostic errors. Int J Gen Med. 2012;5:917–21. doi: 10.2147/IJGM.S38805. - DOI - PMC - PubMed
    1. Rajabally YA. Neuropathy and paraproteins: review of a complex association. Eur J Neurol. 2011;18(11):1291–8. doi: 10.1111/j.1468-1331.2011.03380.x. - DOI - PubMed
    1. De Koning HD. Schnitzler’s syndrome: lessons from 281 cases. Clin Transl Allergy. 2014;4:41. doi: 10.1186/2045-7022-4-41. - DOI - PMC - PubMed
    1. Lebbe C, Rybojad M, Klein F, et al. Schnitzler’s syndrome associated with sensorimotor neuropathy. J Am Acad Dermatol. 1994;30(2 Pt 2):316–8. doi: 10.1016/S0190-9622(94)70031-1. - DOI - PubMed
    1. Krause K, Grattan CE, Bindslev-Jensen C, et al. How not to miss autoinflammatory diseases masquerading as urticaria. Allergy. 2012;67(12):1465–74. - PubMed

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