When you encounter a difficult case in your signing out routine, a case that you are unable to settle its diagnosis, which scenario you go through?
1. Refer the case to a colleague from the start.
2. Write down your findings, your provisional interpretation, suggest a differential diagnosis and ask for further work up, if not available in your lab.
3. Leave the case for a while, may be few days, have a second look on it later.

Actually, each of the above scenarios can be used according to the circumstances.


Sometimes, you have to refer the case from the start because it tackles a disorder or a condition that is not in your field of expertise. In such cases, for the sake of the patient, sending the case to an expert colleague is the most ethical solution. Certain areas in dermatopathology such as melanocytic lesions and soft tissue tumors need very high level of experience in order to make correct interpretation of findings which in certain times can be life saving.

In other situations, simple additional work up can solve a difficult case. Immunophenotyping and immunoflourescence are examples of such work up. The problem is that sometimes you do not have these facilities at your hand and in such cases, you have to write your provisional diagnosis and refer the case to other institutes where further work up can be completed.

In most of the situations, however, when facing a difficult case, all what you need is to leave the difficult slide away for a while, may be a day or two, and re-examine it again. This second look technique sometimes make me see things that I have not seen during the initial examination. It works very well with me most of the times. Sometimes, during a second look, I feel so surprised about how I wasn't seeing it so clearly during the first look!!!!!!!

Anyway, nothing is relieving like reaching the diagnosis of a difficult case!!!!!