werner@aecom.UUCP (Craig Werner) (11/02/86)
<<>> .nf Answer to Medical Puzzle #11 <<<>>> > A young woman brings her 8-year old son to the Pediatric clinic you > are rotating through. Half hysterical, she explains that he has refused > to eat for two days. You examine the child. He is not febrile or weak. > In fact, he is quite healthy looking, as well as restless and uncooperative. > After some effort, you convince him to open his mouth for examination, which > reveals a hard-palate (first half of the roof of the mouth) which is > inflamed, ulcerated, and in a layman's term, thoroughly disgusting. > > 1. What is the best course of action? > 2. What treatment would be recommended? > 3. What is a possible (general or specific) cause? > [ark@alice suggested the child lay off the "Fizzies", a candy of some sort. It's close but not quite.] Let me answer this case methodically. The actual diagnosis is at the end. 1. Best course of action. Do nothing for a week. Most pathology in the mouth is due to trauma, and most mouth trauma will heal in a week. So wait a week - if it was just trauma, it will go away. If it wasn't, a week's wait will not alter the course much. Remember this is a condition of 2 days duration (actually yesterday and today = 2, which is really 1), and the child is otherwise healthy. 2. "The practice of medicine is to do as much nothing as possible" said Samuel Shem, as I have described above. However, an Anxiolytic such as Valium could be prescribed -- NOT for the kid, he's doing fine -- for the MOTHER :-)! 3. This type of lesion - an ulcerated hard palate, the whole thing, has a name, which as you'll see is descriptive of the cause. It's called a "Pizza Sign," and it's usual cause is eating that first slice of pizza when it's still too hot (Stouffer's French Bread Pizza always does this to me). Just to go over some general topics. "Fizzies" or hot liquid would probably burn the tongue and soft palate further back in the mouth. The hard palate is what is hit during the act of biting something. Any lesion in the mouth that doesn't heal within a week or two is to be considered suspicious, especially in a smoker, drinker, or chawer. Any suspicious lesion in the midline, above or below the tongue, will probably turn out to be benign or developmental. Anything off the midline should get thee to a ENT will all deliberate speed. Most oral cancers, I should add, are not picked up by doctors. They are picked up by dentists. In this case, it is probably a case of doctors being farsighted - they try so hard to look back at the throat, they miss the mouth. Some huge oral cancers, though, have been completely ignored or denied by patients, and by huge I mean inches and pounds. An alternate explanation is that nowadays, people go for regular dental checkups but not regular physicals, but that's another topic. .bp Answer to Medical Puzzle #12 <<<<>>>> > A young woman comes into clinic several weeks after trying to > deposit a counterfeit $50 bill in net.jokes complaining of pain and swelling > in the left knee. In addition to her occupational history (see net.jokes.d or > net.women), she has a history of multiple episodes of venereal disease as well > as prior knee problems. There is no history of trauma and no other joints > are affected. She says that putting heat on it, which normally helps, has > been making it worse. During the exam, Cervical, Rectal, and Throat cultures > are taken and are negative for VD by microscopic inspection (and by culture). > > As if I hadn't told you enough already, what is the probable cause of > her knee pain, and what do you do to prove it, and to treat it? An aspiration of the Knee will reveal Gram-negative bacterial coccobacilli/diplococcus, you can bet on it. But to consider a differential of arthritis of the knee. Certain clues come from the history. Rheumatoid arthritis is worse in the morning, Osteoarthritis gets worse with continued use. Osteoarthritis and arthritis due to injury are improved by heat. Septic (infectious) arthritis does just the opposite and gets worse with heat. Aspirin helps Rheumatoid arthritis but not arthritis due to Gout. [wts@burl and cramer@kontron suggested that she may be spending too much time on her knees, as it were. That may explain her previous history of knee problems, but as you can see, is totally irrelevant to this case.] OK, you say, if I'm so sure that the arthritis is due to a Gonorrhea infection of the knee, how do I explain the negative cultures. There are two alternative explanations: 1. The knee infection had to be proceeded by a systemic infection, the bacteria traveling to the knee from the blood and lodging there. It is also a fact that certain antibiotics do not penetrate into the joint space at typical dosages - Penicillin among these. Therefore, the bacteria was safely enscounced in the joint, while the inadequate self-treatment with antibiotics erradicated its traces elsewhere [I suppose another one of the reasons why antibiotics are by prescription only.] 2. An alternative explanation is "Looking for love in all the wrong places." .bp Answer to Medical Puzzle #13 <> > Summary: in short, a 62 year old woman suffering from a symptomatic Iron > deficient anemia. > Having determined that fact, what do you do next? OK, everyone who said prescribe Iron supplements, raise their hand. Come on now, higher, so I can count them. Yes, you in the back too, on the VT100, that's right, don't be shy. Really, all of you said that. Boy, would the lawyers all love you guys... The truth is, the doctor (or even non-doctor) who immediately prescribes Iron supplements for Iron-deficient anemia is probably guilty of malpractice, or will someday be. Despite what you might hear, the average healthy elderly person, is by and large, nutritionally OK. This is not true in all cases, but should not be the first conclusion. No, the first question one should ask, when someone comes in with an Iron deficiency is, "Where's the Bleeding?" In a young woman, the answer is easy, the blood loss due to menses, but post-menopausal women don't menstruate, so if they're losing blood, there must be pathology. The next thing to do is a careful history and pelvic exam. It could be as minor as gastric bleeding due to too much Aspirin consumption, or it could be endometrial cancer, intestinal polyps or cancer, or a variety of other things. Yes, giving her Iron will improve her symptoms, but one may be masking the symptoms of a disease that is treatable now, and won't be treatable when it becomes refractory to Iron therapy. Remember, anemia is a symptom, not a disease, and sometimes treating the symptoms is not enough. .bp Subject: Answer to Medical Puzzle #14 <> > A man comes into your office after having a work-related injury almost a year > previously. He has been on disability ever since and is unable to work > because of the pain. The injury, incidentally, was somehow back-related. > Physical examination reveals legs that are roughly symetrical, both > in muscle mass and in reflexes. Careful examination elicits pain in the front > half of the thigh (from the hip to the knee) as well as the front half of > the leg (from the knee to the ankle. There is no pain below the ankle. Also, > the pain is only in the front half of the leg, not the back half (where the > hamstrings and calf muscles are). In short, pain in the anterior leg from > the hip to the ankle, exclusively. > What condition is consistent with these findings? [I intended to mention that the pain was only in the left leg, not the right, but it is actually better for the conclusion to be bilateral. Although, if it were unilateral, the finding that the legs were symmetrical, although not unusual for a back injury, might have aroused some suspicion in professional puzzle solvers.] In first year anatomy in Medical school, the most important thing learned is not the names of muscles and where they are, but rather their wiring (ie, nerve innervation) and function. For instance, the fact that the diaghram is innervated by the 3rd and 4th cervical nerves explains why diaghrammatic irritation causes pain in the shoulder, or why a slipped disk at Thoracic Vertebrae 10 (T10) will cause pain radiating to the navel. An explanation of the nerve dermatomes (skin distribution of spinal segments) and myotomes (muscle distribution) as well as the tributary system of the peripheral nerves, is beyond the scope of this newsgroup, but suffice it to say it is a very powerful tool. Given that, it can be easily concluded that this person's injury was in the, no, that's not right. It follows nerve distribution of the, hmmm, that's funny. Well, it's dermatome distribution is in the, no, that can't be ..... All dramatic invention aside, this person's complaints cover about 6 dermatomes and three major nerve distributions, and back injuries generally only cause pain in 1, maybe 2, dermatomes, corresponding to the lower (and occasionally) upper nerve root from the site of injury. (Terminology not to be confused with Upper and Lower Neuron.) Similarly, more peripheral lesions follow one, not several nerve paths. So, note how I asked the question. Not "what did the person injure?" but rather "what is this consistent with?" The answer is "The complaints are inconsistent with any physical injury, and therefore there are only two options: Somatization disorder, the pain is real, but of a psychogenic cause; or two, Malingering, the patient is faking because he likes receiving Disability more than working. Depending on the actual situation, he should either be referred to a psychiatrist or a good lawyer. .bp Answer to Medical Puzzle #15 <> > The following is a short classic: > > While on night duty at the Emergency Room in say, Bronx Municipal Hospital, > you encounter someone with the following physical characteristics: > > Blood Pressure 94/62 (Normal 120/80 or so) > Pulse 48 (Normal 80) > Respiration 24 (Normal 12) > > His pupils are mid-dilated and uneven, i.e. one is widely dilated, > the other halfway. He appears slightly disoriented. > What is your proper response in this case? [Also forgot to mention that the body temperature is 97.2 (Normal 98.6F) [If I may bet personal in this revised answer, the correct response - in all seriousness - is "Hi, Craig, what brings you here?" Those, by and large happen to be my vital statistics. In the original posting of this, I preserved my anonymity.] First let me treat this the way most of you probably read it. Someone comes into the Emergency who is Hypotensive (low Blood Pressure), Tachypneic (fast breathing) and hypothermic (low temperature), you're going to assume to patient is in shock (actually you assume it for any injury, but here even more so). Furthermore, while shock normally gives a rapid thready (light) pulse, deep shock might bring the bradycardia (slow pulse) that we see above. Concerning the pupils: any type of head injury is going to produce mild brain swelling. The skull is great protection, but unfortunately it does not allow for swelling, and in the case of increased intracranial pressure, something's gotta give, and it usually is the brainstem, right down through the Foramen Magnum at the base of the skull. Despite it's name (Foramen Magnum = Great Hole), the foramen is small compared to the base of the brain, and something has to get squeezed. Fortunately or unfortunately (depending on how you look at it), one of the first things that gets pressed upon is the extraocular nerves (Cranial Nerves III,IV and VI which supply the pupillary muscles and the muscles for eye movements). In the case of a dilated pupil, Cranial Nerve III of the same side as the dilated pupil is being impinged upon. Responsiveness to light will also be impaired, as will other neurological tests that really have to be demonstrated. Hence, especially in this litigous climate, anyone with anisocoria (unequal pupils) should be considered at risk of brain herniation, treated to reduce intracranial pressure, and sent off to a CAT scan immediately to rule off any space occupying lesions (such as a subdural hematoma, to name one they may have mentioned on St. Elsewhere). Sure this adds a few hundred dollars to the insurance bill, but the results could possibly help save a life. Now let me tell you the real situation. It's seems that a member of my medical school class, whose body, despite being in medical school for two years, is still under the delusion that it is in good shape. He went over to meet a 4th year student doing a rotation at the Bronx Municipal Hospital ER, and after getting lost a few times, met his friend, whose first comment as a sharp ER-doc-to-be was "Do you know you have anisocoria?" "Not only that," he responded, with an attempt at humor, "but my pupils are different sizes." The conversation continued with the rest of his vital signs: BP 90/50, Pulse 48, Temp 97.2F, Resp. 24, and both agreed that had this encounter been near the ambulance entrance, it would have been a quick run to X-ray and Intensive Care. So: The anisocoria: normal variation, about 1-2% of the population has it. The difference between it and the anisocoria of brain herniation is that the pupils are wholely responsive to light. The vital signs: "Athletic Heart Syndrome", otherwise known as very good shape. Not normal, of course.....better than normal. The confusion: Try spending 15 minutes in a Bronx Emergency Room -- you'd be confused too. I just stuck this in to demonstrate two principles: someone may have symptoms but have absolutely no disease (when the symptoms are actually the basis for a complaint, but there is no pathology, it is known as the "Cheshire Cat Syndrome", i.e., having the Grin without the Cat.) The second principle is that written description cannot replace physical examination as the basis of proper medical diagnosis. .bp Answer to Medical Puzzle #16 [Thank you all for your messages, especially those to whom my replies are slowly but surely being returned from intermediate nodes.] Summary: a woman who has chain smoked for forty years comes in complaining of deterioration of vision in one eye. Specifically, her pupil won't dilate in dim light, and her eyelid droops. These are not obviously related, of course, or are they?.... First, all guesses centered on the possibility of a stroke. I should have noted there this no no motor or sensor impairment other than what I described in the puzzle. Let's go on to the questions: 1. What is the cause of the woman's symptoms? An interruption of the sympathetic nervous system to the head. You see, one of the poor points of human wiring is that sympathetic nerves only originate in the thoracic segments of the spinal cord. The supply to the head has to go all the way down to the chest and come all the way back up, which makes it pretty vulnerable. Anyway, it controls the dilation of the pupil, the raising of eyelid, and sweating (see below) on that side of the face. That is the cause of her symptoms. 2. What is the cause of the woman's symptoms? Among the things that can interrupt the ascending sympathetic nerve supply are of course trauma and also mass lesions, including tumors, that can impinge upon the nerves. The most common mass lesion is a tumor of the apex of lung (so-called Pancoast tumor). This was in fact the case, so "Lung Cancer" is the cause of this woman's symptoms. 3. What is the cause of the woman's symptoms? 85% of all lung cancers are directly attributable to cigarette smoking. The 15% that aren't tend to be in the lung bases, because they occur randomly, and most of the lung mass is in the base. However, air breathed deeply (as in a cigarette puff) tends to go to the apex first, so that almost all apical (Pancoast) tumors of the lung are secondary to cigarette smoking -- almost ALL. Therefore, cigarette smoking is the cause of this woman's symptoms. [Extra-credit: the triad of miosis (small pupil), ptosis (drooping lid), and anhydrosis (no sweating) is called Horner's syndrome. I must acknowledge Philip Ledereich, who by saying "Craig, you should do a puzzle on Horner's Syndrome." prompted me to dig this puzzle out of my attic.) [As for the mail, credit goes to Lynn Soffer, soffer@sunybcs, for getting both the Horner's and Pancoast eponyms.] (*) The third symptom (lack of sweating) is difficult to test for, especially in colder climates and air conditioned offices, although a recent letter to JAMA pointed out that Horner's syndrome patients have non-symmetrical perspiration stains on their hatbands (if they wear a hat, that is) and that this may be of clinical usefulness. Reference: L. Doss, "The Hatband Sign in Horner's Syndrome" (JAMA, June 13, 1986; 255:3116) Epilogue to Medical Puzzle #16 <> Since with a large probability, the acknowledgment got lost in transit, I would like to thank (in the order received): Jerry Hollombe, Dave Spencer, Dave Kasses, Barbara Petersen, Laurah Limbrick, Joe Yao, Paula Matuszek, Lynn Soffer, Jeff Kushner, Susan Finkelman, Matt Fichtenbaum, Michael McNeil, David Robins, Robert Plamondon, Dave Grooms, Dave Shema, Maurice Suhre, Ken Shirrif, Guy Riddle, Peter Rubin, and Andrew Klossner for verifying that 1) our site can transmit out and 2) net.med is still healthy. The other note is in regards to the style of the question, i.e., asking the same question repeatedly, but with different answers in mind. I borrowed this device from the Brhadaranyaka Upanisad, particularly the dialogues of Yajnavalkya and Gargi Vacaknavi ("On what then, pray, is the water woven, warp and woof?" ...), and of Yajnavalkya and Vidagdha Sakalya ("Yes, but how many Gods are there, Yajnavalkya"?) [See: Radhakrishnan and Moore, A Sourcebook of Indian Philosophy] .bp Answer to Medical Puzzle #17 <> Summary: A woman in for routine surgery with no history of bleeding disorders is now found to have a generalized clotting defect, which after extensive workup is found to be caused by an isolated Factor V defect. Other than that, the patient claims to be in perfect health -- in fact didn't even notice this problem. Oh, you also know that the onset of the defect is sometime after age 22 since she had her appendix out (read previous surgery) at that time. I had to give you the Hematology lesson to both highlight and obscure the following fact: Factor V is made in the liver, and is the only liver-derived factor that does not require Vitamin K (*). Hence, it is the only factor for which the synthesis in the liver is the rate-limiting step (for the others, the Vitamin-K mediated Carboxylation is the slower and limiting step). Ergo, it is the first sign of liver problems (**). (*) I know, you say, careful reading of the lesson says that Factor I (Fibrinogen) is also made in the liver. Well, it is, but much larger quantities than any of the intermediate factors. (**) Actually only liver problems that don't involve the bile ducts. When the bile channels are involved, fat absorbtion is impaired, and Vitamin K (a fat soluble vitamin) may become deficient first. So what causes liver problems (or more specificallly, Hepatocellular problems) that you know about. 1) Hemochromatosis is the most common - but I said this woman is borderline anemic -- that elimates that (Hemochromatosis is a genetic buildup of Iron in the body. When the exact thing happens by Iron Overload -- Blood Transfusions or too many vitamins pills - it's called Hemosiderosis. I covered this in an earlier puzzle.) 2) Alcoholic cirrhosis. This woman is in the risk group for alcoholism. Normally, male alcoholics outnumber women 3-1, but among physicians, the percentages are equal. So while male physicians are no more likely to be alcoholics thab non-physicians, female physicians are at a triple relative risk. As it turned out, the woman in question was a "closet" alcoholic. (where alcoholism is defined as, well, come to think of it, nevermind :-) ) Alcoholism can present as anything, and this was a relatively unusual presentation. For this reason, alcoholism is known as "The Great Masquerader." The synergy between her alcohol consumption and her exposure to anaesthetic agents as part of her work, may have accelerated the damage to the liver, as well. Also, her consumption of Acetominophen may have accelerated the liver damage. It turns out that it synergizes with alcohol, and may damage the liver even at therapeutic doses in alcoholics. Normally, only a massive overdose of Acetominophen (Tylenol) will damage the liver. This puts one in a bind, since Aspirin prolongs bleeding and alcoholics tend to have bleeding ulcers (perhaps this explains her borderline anemia, perhaps her borderline anemia is related to why she was undergoing a D&C in the first place. Each one as its disadvantages.) .bp Answer to Medical Puzzle #18 <> Summary: on a chilly spring morning, while surveying his dairy herd by walking the perimeter of his farm, 55 year old Farmer Bob, starts feeling dizzy and faint, and starts to lose consciousness. He lands against his electrified fence and hits the ground a little jolted but no longer faint. The same thing happens a week later, although this time he voluntarily makes contact with the fence, with immediate improvement. The hint was that he had Strep throat as a child (and this would be before Penicillin was discovered). The questions were: 1) Explain the dizziness. 2) Explain the fence. Actually this one gets a little tricky. I could have come out and said he had Acute Rheumatic Fever as a child, but he didn't mention it to the doctors, and besides they assumed it anyway. Acute Rheumatic Fever is a late sequelae of Strep Throat. In fact, it is the reason why Pediatricians (Strep throat occurs primarily in children) treat strep throat with a 10 day course of antibiotics. The throat will get better in a week whether you treat it or not, but treating it thoroughly will eliminate the risk of later Rheumatic Fever. Hence Acute Rheumatic Fever is much rarer now than it was prior to the 1950s. Anyway, acute Rheumatic Fever affects the heart valves, particularly the left-sided valves, almost always the mitral (connecting left atrium to left ventricle) and frequently the aortic as well. It builds up scar tissue, damaging the valves, which continue to get more scarred as time goes on and the heart beats on. Eventually the mitral valve (let's say that's its an uncomplicated pure mitral involvement) becomes so stenotic that it cannot permit adequate blood flow into the ventricle. So assuming mitral stenosis, how does the body cope? Well, for one thing, the left atrium - the chamber that has to push through the hypertrophies (adds more muscle) and dilates (adds more volume). This works for awhile, or even indefinitely, but there is a cost. Hypertrophied muscle and the larger volume translate to greater surface area and muscle thickness, presenting problems both for electrical conduction and for blood perfusion, in that both the oxygen and the current both have more places to go. Now let's add some physical stress to the situation: a long walk in chilly weather, get the heart beat up, up past the point where the heart is beating faster than current can conduct through the hypertrophied atrium, and what do you get? Well, let's assume we get the most common heart arrythmia: atrial fibrillation. A. Fib is not life threatening like Ventricular Fib - people walk around with A Fib for years. However, sudden onset of AFib will lead to decreased pumping across the mitral valve by the atrium, with less blood coming in, the left ventricle will pump less blood out, less blood enters the carotids to the head, faintness results. Had he merely fell on the ground, he probably would have recovered as his heart rate slowed down, however he hits the electrified fence, and thereby rediscovers the principle of electrocardioversion: the restoral of normal sinus rhythm by application of a transient electric shock. (Don't try this one yourself, electrical current, especially AC, more often starts Arrythmias than stops them) The fact that the fence restores him adds further support to the formal argument that exertion-caused Atrial Fibrillation was his problem. [The closest to the correct answer was Jeffrey Silber, devvax!silber. Both alice!ark and hadron!jsdy came close.] [Also to clarify the fence: cattle containment fences are short frequent DC pulses at high voltage, low amperage current.] .bp Answer to Medical Puzzle #19 <> The case: > An 18-year old female college freshman begins to act strangely > about a week after breaking up with her boyfriend that she met during > orientation (the time is now February). She undergoes a dramatic change > of personality, going from a quiet, sweet, and shy to abusive, agressive, > and disruptive -- all within a few days. She also has sleep difficulties, > loss of appetite, and no longer cares for her personal appearance. After > creating a disturbance on the campus quadrangle, she is forcibly delivered > by the campus police to the local hospital, where she is diagnosed as > having an acute psychotic episode, possibly early schizophrenia. She is > admitted and is being wheeled by a resident to the psych ward for > evaluation. > On the way, the resident notices something, and has her transferred > to the medical service instead. (OK, I'll be a little more explicit: she > has a fever -- and he suspects a seizure) > > Now then, if I tell you that the resident, by noticing the fever > and acting on a hunch, probably saved the girl's life, can you answer > the following questions? > > 1. What is the cause of the woman's behavioral change? > 2. What is the most likely reason for her breaking up with > her new boyfriend? Let's assume that there really was a seizure, and that it wasn't just secondary to a high fever (for as you probably know, seizures/convulsions can occur secondary to any high fever). So let's then go to the behavior. 99% of the time someone presenting with acute psychotic symptoms falls into one of two categories: Prodrome of schizophrenia, or any one of a number of drug abuses (Cocaine, PCP are two common ones these days). Ruling out drug use leaves Schizophrenia, with a 99% certainty. Of course, it's the other 1% that will get you into trouble: Wilson's Disease comes to mind (it's a hereditary disorder of copper metabolism that becomes symptomatic at early adulthood. It leads to liver, behavioral, and neurologic disorders, as well as in most cases, Copper rings in the eyes: so called Kaiser-Fleischer rings) Wilson's Disease is rare,but treatable - it's one of those hundreds of diseases that will probably never be seen,but it taught because it should never be missed.) However, Wilson's doesn't present with Fever, nor so suddenly. The behavior is distinctive, however. It is (to coin a Freudianism), all Id. We have compulsiveness, loss of control, loss of desire to eat, etc. To a rough approximation, that sounds like functions controlled by the Limbic system of the Temporal Lobe of the brain. (The Limbic System is said to control the 4 Fs: Fighting, Fleeing, Feeding, and Reproductive Behavior). [I mentioned that the diagnosis was psychosis, yet my description also fits an affective disorder (mania or depression), as pointed out to me by William Smith. Psychosis also includes Hallucinations - both visual and auditory. These were present in this case, but I said psychosis without describing them explicitly.] So let's focus on infection: an infection of the Brain is referred to as Encephalitis, an infection of its linings as Meningitis. Encephalitis is the rarer of the two. It is generally viral in nature. Vector (insect)-borne encephalitides include Eastern Equine Encephalitis, St. Louis Encephalitis, and California Equine Encephalitis. In an easy to remember guide, Eastern is the most severe, Californian the most mellow, and St. Louis roughly intermediate in severity. They are all rare, a few hundred cases a year. There is a much more common form of Encephalitis however, accounting for a few thousand cases a year (still rare by absolute standards) caused by Herpes Simplex, usually Type I, usually as a primary infection. Herpes Encephalitis tends is unique in two aspects: it tends to localize in the Temporal Lobe, and it tends to be hemmorhagic. It is in fact, the #1 leading cause of Encephalitis (although most cases occur in newborns born to mothers with active herpes at the time of birth) This last disease, however, does fit the case description, so we can diagnose the symptoms as secondary to acute Herpes Encephalitis, and the relationship difficulties as probably secondary to other manifestations of the primary Herpes infection. In a way, this woman is lucky. Had it been acute Schizophrenia, there would have been no cure. But Herpes Encephalitis can be treated if caught early with Antiviral drugs (Ribavirin & Acyclovir/Zovirax), and if caught early enough, lead to complete recovery (with, as they say, no permanent sequellae). I call the Resident a hero in this case because by acting on his hunch instead of the probabilities, he at the least prevented permanent brain damage, and quite possibly saved the woman's life. [Credit to William Smith (uiucdcs!wsmith) and Beverly Erlebacher (Mail returned - unknown site) for suggesting Encephalitis, albeit not the specific etiology, and special honorable mention to Jane Talisman, for being the first person ever to provide an answer to a medical puzzle by 1st class stamped mail.] .bp Answer to Medical Puzzle #20 <> > A 19 y/o woman comes into the emergency room with acute and > excruciatingly painful left lower quadrant pain (that's abdominal pain > right around or below the level of the umbilicus/navel/belly button). > There is abdominal muscle rigidity, guarding (she winces and withdraws > from touch, a sign of pain), tenderness, and rebound tenderness > (i.e., if you press on the unaffected, that is, right side, there is pain > upon release on the affected opposite side.) > The examining doctor on the basis of classic signs make an immediate > diagnosis, then immediately reconsiders in favor of another diagnosis that > fits the the symptoms equally well, in fact, fits them better. > Other notable physical signs are a fever, diffuse congestion in > the lungs, and "distant" heart sounds, as ascultated (listened for with > a stethoscope) at the Apex beat in the Left Mid-Clavicular Line (the usual > place to listen). > > Questions (and answers) > 1) What are the two common syndromes that fit the symptoms? Actually there are three, not two. the triad of one-sided abdominal pain, rigidity, and rebound tenderness (especially rebound tenderness) are classic for acute appendicitis. There is just one catch - the appendix is on the right side, and the woman's pain is on the left. The much more common cause for left sided pain (especially in a young woman) is either PID (Pelvic Inflammatory Disease), or a ruptured ectopic pregnancy. Ruptured ovarian cyst is also a possibility. > 2) Which one do you think that the doctor picked first, and > why do you think he did so? It's obvious that the doctor picked Appendicitis first, presumably because he acted in haste, or alternatively (like me) is Cryptodextrous, i.e., can't tell his right from his left without thinking about it. > 3) Given that the first guess is in fact the correct one, and > that One question and One simple examining manuever will rule it in, and > the other out, suggest the Question and the Action. > Taking a sexual history can be very important in this case: if the woman is a virgin, then ectopic pregnancy is impossible, and PID is highly unlikely {PID is usually caused by the sexually transmitted organisms, Neisseriae gonorrheae (Gonorrhea) and/or Chlamydia trachomatis (Chlamydia). Other non-sexual causes are rarer.} To rule in appendicitis, one must determine that the appendix is really on the left. It turns out that in a condition Situs Invertus, more properly called 'Dextrocardia with Situs Invertus' all of the abdominal organs are mirror images of normal (hence this conditioned has been dubbed by anatomist Francis Baker-Cohen as 'Vice versa viscera'). Notice, when describing the heart sounds, I noted that they were 'distant'. This is actually a technical term, and usually signifies that there is fluid in the pericardium that dampens out the heart sounds (which are caused by and large by the heart valves closing). They can also can sound distant in very obese persons. However, if you haven't guessed by now, the reason they sound distant in this person is because they are distant, they are coming from the other, the right, side of the chest. Hence, placing a stethoscope on the right chest, and determining where the heart is, can rule in a right-sided appendix. Situs invertus is usually associated with an 'Immotile Cilia Syndrome' (Kategener's Syndrome) where the microtubules in the cilia lack Dynein arms normally involved in cross-linking and movement. Since cilia are involved in clearing the airways, bronchietasis and sinusitis are the result (hence the diffuse congestion in the lungs seen here). Cilia are also involve in Sperm motility and in transport of the egg down the Fallopian tubes, hence these people are also sterile (Actually, females with this disorder can have their eggs fertilized in-vitro and reimplanted). Finally, 50% of cases of 'immotile cilia syndrome' have situs invertus. Ciliary motion is directional, and this directionality insures that in embryogenesis, the organs always rotate in the same direction. In the absence of ciliary movement, the rotation is random, and situs invertus results in half the cases. The Dynein Arm defect is inherited as an autosomal recessive gene and occurs at a frequency of 1:20,000 among whites (Robbins, 3rd, p. 730) -- Craig Werner (MD/PhD '91) !philabs!aecom!werner (1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517) "Reading is sometimes an ingenius device for avoiding thought."