werner@aecom.UUCP (Craig Werner) (11/02/86)
<<>> .pa Answer to Medical Puzzle #1 Subject: Punch Line - the mystery "tumor" revealed. Newsgroups: net.med Distribution: na <> From the mail: --> I never heard the punch line, promised for "next week", from the story --> about the patient whose doctor asked him to take off his socks. --> -=- Andrew Klossner (decvax!tektronix!tekecs!andrew) [UUCP] --> You ever going to give us the punchline to the joke you started about --> a month ago? --> -Ron Natalie Sorry, I gave away my modem to give me more time to study infectious disease. To summarize the original posting: a comedian speaking here at Einstein told of a "cancer" he had in his groin, how he was convinced he was going to die, and how eventually a Surgeon took a look at the lump, and asked him to take off his socks. At this point we started laughing innapropriately before the "punchline", but of course we knew why. I left off at this point, adding only that in a retrospective study, this was the cancer that was cured most often in Mexican Laetrile/whatever clinics. Well, what was the tumor, what does it have to do with feet, and why did we find it so funny? I'll give it away. It wasn't cancer, it wasn't even a tumor. It was a focal inflamed lymph node. The comedian in question had been trimming his toenails the week before and cut a little too deep, the toenail got infected, probably by a bacteria called Staph epidermidis, although it could be a number of bacterial strains. Anyway, the bacteria migrated up the lymphatics and eventually lodged in the femoral lymph nodes, where it mimicked a fast growing tumor, at least to the patient. If it happens in a fingernail, it would be the cervical lymph nodes, where it has been mistaken for Breast Cancer. Although since 2/3+ of women will get short-lived lumps in their breasts, this forms the basis for most false cancer alarms in women. .pa Answer to Medical Puzzle #2 For those who forgot the question: > History of present illness: Two weeks ago the patient had a bout of > severe epigastric (that's directly underneath the belly button) pain and > nausea that lasted a little more than 12 hours and then went away. However, > two days after that he felt a little tired, and has had a continuous headache > ever since, and sweating and chills (and presumably fever) at night. However, > he feels fairly good, albeit fatigued, and his physical exam reveals > nothing remarkable, and routine tests are normal. > > Contained in the above is a Classic symptom of a disease. It should be For those who didn't get it, one other piece of information should prove relevant. On physical examination, pressing on the left side of the abdomen was painless but upon sudden release there was pain on both the left and right side (this is known as rebound tenderness). If you still haven't recognized it, here's the answer: Burst appendix -- the acute pain underneath the belly button is a Classic sign of acute appendicitis in its early stage. The reason it is central is because all visceral pain is referred to the navel in that area of the body. Appendicitis can progress either of two ways: it can go to the parietal (outside) surface, with the pain localizing to the right side where all of you were taught the appendix lies -- OR it can do what it did here - burst, whereupon the pain goes away but there is spillage of the gut contents into the abdomen (peritoneum). The various contents can try to wall off the infection (specifically the Greater Omentum) but its kind of like Napoleon's retreat from Moscow. The nightly headache and sweats are due to fever caused by Sepsis -- bacteria in the blood. However, it was a small amount, since the blood culture taken was negative for bacteria -- a sign that the infection was being contained fairly well. Now for the unhappy part: this is an actual story (from 1970). The only change was that the patient waited 8 weeks before seeking treatment. The diagnosis -- obvious from the history and rebound tenderness -- was actually missed by the treating physicians for three days because of the unusual (8 week delay) presentation. His appendix was eventually removed, and antibiotics were given, but the patient died of peritonitis and septic infection two weeks into the hospitalization. They give this case to us because this should not have been missed, and they wish to see it never happens like this again. The happy ending: in the last fifteen years, at least (that have been reported back) four cases of missed burst appendix have been diagnosed by Einstein Medical students, with survival of all four. .pa Answer to Medical Puzzle #3 To refresh, the symptoms as related by phone: > For the last week or two, the woman (age 45-50 or so) felt bloated > after meals - it was much worse after eating fried foods (so she had to give > up cooking in a wok). Not only that, but in the last week, about an hour > after eating, she developed sharp colicky pains in her right shoulder, and > felt sick and nauseous. First the point of medicine: due to a quirk of developmental biology, the nerves of the diaghram arise from the same point in the spinal cord as the nerves to the shoulder, and hence imflammation of the diaghram is "referred" to the shoulder, i.e. the brain can't tell the inputs to the 3rd and 4th Cervical Nerves apart, and assigns the pain to the most likely candidate, in this case the shoulder. (Remember in the appendicitis case, the pain was referred to the midline and expressed as being near the naval) Hence, the obvious question is, is there also pain on the right side below the diaghram. The answer was, of course, "Yes." Now, there is only one thing below the diaghram on the right side that 1) is involved in the digestion of fat [ the bloating post-fried foods ], and 2) contracts to produce cholicky, that is rapid, intermittent, sharp, pain. As I said, the obvious (:-?) diagnosis is the correct one -- the woman was having Gall Bladder attacks, or, in medicalese, Cholecystitis. Her doctor's appointment the next day confirmed the "diagnosis" by Ultrasound, and she was operated on and divested of her stone-filled and heavily inflamed gall bladder within a week or two. Epilogue: The patient has had no trouble since, but half just-to-be-sure and half out of appreciation, presented me with her newly bought Wok soon afterwards, which remains in my possesion to this day. For those who didn't get it -- don't feel so bad. Most gall bladder attacks hurt on the side where you'd expect them too, this is the more unusual presentation. And as further solace, a few of my classmates who I gave this puzzle to got so hung up on the diaghrammatic pain referral that they blocked on the next step as to what was causing it. However, it WAS Exam week, so they weren't at their best on topics not necessarily at hand. .pa Answer to Medical Puzzle #4 > Since people's skin color varies, to determine the extent of jaundice, > you examine the whites of the patients eyes. One eye is almost orange. The > other is totally normal-looking, showing no signs of jaundice. In addition, > the non-jaundiced eye is not responsive to light. There is only one way an eye could escape being jaundiced, and that's if it's not connected. Since unconnected eyes don't last too long, the other possibility is that it's fake -- which it is, and Glass Eyes don't respond to light. That was the non-medical part of the puzzle. And congratulations to mlf@panda (Matt Fichtenbaum), trudel@caip (Jonathan D. Trudel), and hollombe@ttidcc (Jerry Hollombe). Given a glass eye, then you have to make the medical leap. The most common reason for removing an Eye surgically is Cancer of the Retina, the most common metastatic cancer of the retina is Malignant Melanoma, and one of the favorite sites for distant metastases of malignant melanoma is, you guessed it, the Liver. Most likely diagnosis: liver metastases of a malignant melanoma derived from the retina. I should note that this is a rare but not unheard of condition. John Wurzelmann has seen two. A friend at another Medical School called me back two days after I told her this story, to say they had a patient with the above at their hospital, and a saying amoung the housestaff, "Beware of man with one jaundiced eye." .pa Answer to Medical Puzzle #5 <> > A young woman comes into the clinic with (obviously) a health complaint. > > You ask what's wrong, and she says that her stomach hurts. > You ask her to describe the pain further, and you find that it > is worse before she eats breakfast. > You ask how long this has been going on, and she says it started to > bother her a few weeks ago, but has gotten worse recently. > You ask two more questions, the first of which is suggestive but > non-specific, the second of which suggests the obvious diagnosis? > > What is the informative question, and why do you ask? This was an actual situation. The next question asked followed up on the stomach (GI) symptoms, asking "Do you feel nauseous?" She didn't understand "nauseous." Rephrasing, "Do you feel like you're going to throw up?" She answered, "Sometimes." There was a slight pause as all the differential diagnosis of GI disease goes through your head, competing to be the next question, then all of a sudden, it dawns on you to forget about that and ask: "If I may ask, when was your last menstrual period?" She answered January, and this was in April. The diagnosis: morning sickness secondary to pregnancy. The interview continued for 10-15 minutes with eventual referral to family planning. I was once told to remember three easy hints to catch the obvious: the most frequent cause of amennorhea is pregnancy, the most frequently found Suprapubic mass is a full bladder. One of my letters suggested an Ulcer. This would be a proper first guess in a man of 40, not a young woman. Also, ulcers tend to hurt most a few hours after each meal, not just in the morning. Note, however, that if she had NOT been pregnant, this would have to be considered. .pa Answer to Medical Puzzle #6 <> > A 27-old Hispanic female from the South Bronx is referred to clinic > with a 2-week history of dry cough, fever, shortness of breath, and weight > loss. On physical exam, she has a temperature of 102. An examination of her > head reveals oral thrush (an infection of the mouth by the yeast Candida). > Because of her extreme difficulty breathing, she is admitted to the > hospital. An admission chest X-ray reveals is diffusely cloudy on both sides, > suggesting interstitial pneumonia. Routine blood test shows mild anemia (low > hematocrit) and a White Blood Cell count in the low normal range. > > What is the suspect diagnosis? Oral Thrush (Candida) is diagnostic of a prounounced Cell-mediated Immune Suppression. (It also occurs during the use of broad-spectrum antibiotics which eliminate native flora - and the mouth is an exceptional dirty place, so there are a lot of native flora to eliminate.) Anemia is a non-specific sign of either malnutrition or chronic disease, but can also occur independently or related to specific diseases. The white blood cell count is in the normal range. But given a Pneumonia, one would expect it to be elevated. So, seeing it in the normal range is akin to seeing it depressed. This is in agreement with the findings of oral thrush. What causes Cell-mediated immune suppression: Steroids - most commonly given for treatment of certain illnesses (iatrogenic immune suppression) but also can occur in Ovarian and Adrenal tumors, which can produce large amounts of Steroids (moreso Adrenal), or in Pituitary (Brain) Tumors, which stimulate the Adrenals by releasing the hormone ACTH. Note: Physical stress also causes release of ACTH, but the immune suppression is rarely quite this severe. Cancer - many kinds of cancer can cause both anemia (Red Blood Cell) and immune suppression (White Blood Cell decrease). In a young woman, Hodgkin's Disease, non-Hodgkin's Lymphoma, and Leukemia are the most commonly encountered Cancers. In the past, there would be an extensive workup looking for possible tumors. Now, the first step is a careful examination of the extremities, (What are we looking for? SEE BELOW.) or a careful sexual history. The Pneumonia: Pneumonias come in three types: Bacterial, Viral, and Fungal. Bacterial is what is generally thought of as Pneumonia classicly, and it causes the classic consolidation of lung into solid fluid and pus, visible as white on X-ray. Viral is more common in healthy people, and is self-limiting, although may cause breathing problems so bad during its course that hospitalization is necessary. This is called ARDS (Adult Respiratory Distress Syndrome). Fungal is only seen in immune suppressed patients or secondarily to TB. It's course is generally bad, not because the organism is virulent, but because the only people who get such pneumonias are dreadfully ill to begin with. A spotty interstitial type of pneumonia would be viral or fungal, or even miliary Tuberculosis (not common since the 1950s in this country) As it turned out, the patient's pneumonia was caused by the organism Pneumocystis Carinii, a protozoan. This too is seen only in immunosuppressed patients. THE DIAGNOSIS: Admitted for: ARDS (caused by Pneumocystis Carii) Underlying Condition: AIDS (Acquired Immune Deficiency Syndrome) As I noted above, examination of the extremities revealed significant needle tracks, but the hint stated that she had been referred from Methadone maintenance. Hence, she falls into the Intravenous Drug User Risk Group. Confirming the Diagnosis: #1 A differential White Blood Count was done was which revealed an inverted T4/T8 ratio (T4/T8 = 0.2) with low absolute T4 numbers Explanation: T4 cells are helper cells. T8 are both Suppressor Cells and Killer Cells (probably two cell types, but no one's yet been able to tease them apart) The ratio can be inverted because of two reasons: 1) Less Helper and More Suppressor, or 2) Simply more Killer T8s, which happens in many illnesses, but in which T4 count is normal or elevated. #2 An Enzyme-linked Immunosorbent Assay (ELISA) was performed on the patient's blood, and was positive for Antibody to HTLV-3. I took a lot of time to explain this one, because two people wrote me that they had those symptoms. It was an abbreviated description, and I don't want them to think "Oh no, I've got AIDS." Perhaps this long differential also gave you some insight into the workings of the medical model. [Feedback, anyone?] .pa Answer to Medical Puzzle #7 <> > A young recruit, previously healthy, comes into clinic after being > ordered to see you by his drill Sergeant. > As he sits head upright and straight as an arrow, he tells you his > symptoms, which are: "I feel real tired, Sir. I've got the worst headache > I've ever had in my life, and my eyes hurt in the sun." He also has a > temperature of 102. > After discussing the case with your attending physician (and Senior > officer), you discover that you have no choice but to immediately admit this > person to the hospital for diagnostic tests. > > 1. What is the suspected diagnosis and why has it been written into > MilRegs (Military Regulations)? > 2. What obvious symptom isn't the patient telling you about (Read > carefully!) > 3. What's the test to do in the hospital? The hidden symptom is a stiff neck, which could fairly easily be mistaken for proper erect military posture, even in a civilian. So we have: Stiff Neck (also called Nuccal Rigidity), Headache, Photophobia and Fever. These are the classic signs of Meningitis. Meningitis, an infection of the lining of the brain, can be caused by bacteria (the exact bacteria varies with patient age), fungi, or viral. Bacterial meningitis, which in and of itself, is the worst form of the disease, is also the most frequent form of epidemic meningitis, particularly among military trainees, who live in such close quarters. Hence by MilRegs, any soldier with a fever of 102 or greater and a headache must be admitted to the hospital with presumed Meningitis until proven otherwise. [See end of the article.] The test to do in the hospital is a Spinal tap (also called a Lumbar Puncture). Examination of the Cerebrospinal fluid will yield a diagnosis. Normal CSF is clear, has very little cells, has ample Glucose, and very little protein. Bacterial meningitis will cause a Turbid CSF, caused by Polymorpho- nuclear White Blood Cells. Bacteria may also be seen, and probably can be cultured. Also, Glucose will be low, and protein high. Sometimes this is the only clue. Viral will usually have less cells, they will be mononuclear, glucose may be normal, and protein only slightly elevated. Ditto Fungal (although in fungal - you also need suspicion, since people who get fungal are always ill to begin with.) [Got that: they'll be a short quiz later on] I should also note two things. 'Classic' in general medical usage means 'Seldom, if ever.' Also, the chances of someone with a fever, headache (w/ or w/o Photophobia - after all many migraines headaches come with photophobia) , and stiff neck actually having Meningitis is something along the lines of 3%. Of course, doing 97 needless spinal taps is probably worth the 3 that come up positive, since Bacterial meningitis is very contagious, is very damaging, and is very treatable. (In adults, Neisseria meningititis is almost always Penicillin sensitive, unlike its cousin N. Gonorrheae.) Hence the odds are that this person has the Flu, and the stiff neck is due to strain (the most common cause of stiff neck) or the myalgia associated with fever. On the other hand, one must rule out Meningitis, or the lawyers will descend without mercy (not to mention the potential damage to the patient). .pa Answer to Medical Puzzle #8 <> > Another patient comes into the hospital heavily jaundiced. (And, the > whites of BOTH eyes are deeply orange.) He had been seen in clinic for > another (and for this puzzle, unimportant) illness two weeks earlier and had > been prescribed tetracycline based on a history of Penicillin allergy. > Other than that, he had been previously healthy. > To confirm the initially obvious diagnosis, a liver biopsy is done, > and much to the suprise of the residents, it does not reveal membrane bound > fat accumulation typical of idiosyncratic Tetracycline toxicity, but rather > large quantities of iron in almost all the liver cells. > The blood count is normal, as is the hematacrit, so there is no > sign of hemolytic anemia, or increased Red Blood Cell destruction. > > 1. What was overlooked, and what needs to be done to remedy the > situation? > 2. What is your best guess as to the cause of the liver failure? If you didn't pick it up, a RARE reaction to Tetracycline is to develop a fatty liver, with secondary failure if severe enough. The reaction is idiosyncratic, meaning there is no way to predict in advance that it is going to happen to any given person, but known. Other causes of Fatty liver include Alcohol consumption (the #1 cause) and Carbon Tetrachloride. However, in the latter the fat is free in the cytosol, and in the former, it is membrane bound. The two look distinctive enough not to be confused. Incidentally, it gets better if you stop the antibiotic, ditto the alcohol. However, that's NOT what the patient had at all. Tet toxicity does not cause Iron accumulation in the liver. (which is a test result, not a symptom) What does cause Iron to accumulate in the liver: the number one cause is Red Blood Cell destruction - hemolysis. This is called Hemosiderosis. Another cause for the St. Elsewhere fans on net.med, the liver may congenitally be unable to rid itself of Iron and it accumulates in the liver and pancreas over a lifetime -- this is Hemochromatosis. The last reason is the accumuation of Iron due to excessive intake -- since men can only remove 1 mg/day from the body, women slightly more due to menstruation. Answers: What had been overlooked? Well, the patient had been asked what medication he had been taking. He answered Tetracycline. What should have also been asked was whether he was taking anything else non-prescription or otherwise on his own. As it turned out, the answer was "Yes." He had been told to take a gram of Vitamin C a day by a well-meaning friend, and instead of doing that, he took 12 Multivitamins+Iron (well, 80mg each * 12 = 960mg ~= 1g) on the assumption that if C was good A-E+ would be even better. The diagnosis: Hypervitaminosis Iron (essentially Heavy Metal poisoning). Alternate phrasing (a sort of pun for those who really know liver: 'Chronic Active Gullibility/Stupidity with Acute Exacerbation.' Treatment: Talk to the patient. Convince him of the error of his ways. Also: Deferoxamine, a highly specific Iron chelating agent might speed up the recovery (which would happen anyway, albeit slowly.) .pa Answer to Medical Puzzle #9 <<>> > A up-and-coming liability lawyer is in your office complaining of > alternating constipation and diarrhea, with occasional tenesmus (painful > non-productive bowel movements -- more colorfully described as dry heaves > of the Rectum), occasionally passing just mucus, or just a pencil thin > small stool. There is no gross blood as far as he can tell. He denies any > indigestion at any point, although occasionally says he has some lower > abdominal discomfort associated with the episodes of diarrhea and tenesmus. > His father died at the age of 57 from cancer of the colon, although > the patient denies any concern that this might be cancer -- repeatedly -- > without prompting. > > 1. What does the patient almost certainly have? > 2. What could the patient have, but almost certainly doesn't, but you > had better make sure in light of his profession? To give away the answer right away, the man is suffering from Irritable Bowel Syndrome, which actually afflicts women more often than men, but when it afflicts men, it tends to affect Accountants and Lawyers preferentially. The best description I have heard of Irritable Bowel is the following: "Although there are those who would link Irritable Bowel Syndrome [Spastic Colon] to a generalized conduction disorder of smooth muscle, it is most likely just a pain in the, well, propriety forbids me." It is probably a variant of normal, although not a very pleasant one. The trouble is that normal is defined as whatever is usual for the patient, which is usually anyway from three bowel movements a day to one every three days, despite the propaganda you here on Television from the makers of Ex-Lax. Increasing the amount of fiber in the diet helps some people, although not all. But since it doesn't cause any structural damage, only discomfort, the best therapy is to convince the patient not to worry about so much. Oh, the differential: from one end to the other, the patient could also have a Duodenal Ulcer (although he denies any indigestion), Crohn's Disease (Ileitis), Ulcerative Colitis (Crohn's and UC are both classified as Immflammatory Bowel Disease [IBD] versus the minor IBS. The initials cause as much confusion as the fact that they may initially present with the same symptoms. A simple $3 Guaic test for occult blood in the stool would probably rule out anything major and make the Insurance company happy, but as a form of defensive medicine (against lawsuit) a Barium swallow, a Barium enema, and endoscopy could be performed with similarly (almost guaranteed) negative results at a cost of hundreds of dollars. I mean, you figure this guy didn't become a hot-shot liability lawyer for nothing. .pa Answer to Medical Puzzle #10 <<>> > A 52-yr old housewife comes in with two complaints. Over the past few > months, she had dropped 7 dishes, and had to switch to washing dishes with > her left hand, at which point the china breakage stopped. She also said that > she had trouble holding a pencil while writing, and dropped it repeatedly. > She also has another symptom, but hasn't noticed it. Additionally, > there are findings you can elicit on physical exam. To tell you which would > give away the answer. > What is the most likely diagnosis? Taking the above description at face value, frankly it could be anything. In fact my test run with John Wurzelmann produced the following: >> My differential diagnosis would include myasthenia gravis, diabetic >> mononeuropathy, amyotrophic lateral sclerosis, & carpel tunnel syndrome. >> Other diagnostic possbilities include lead poisoning, syringomyelia, >> myotonic dystrophy (I don't think it's X-linked), shoulder-hand syndrome. which is as good a list of diseases as I can come up with. However, let's go at systematically from the top. She could have had a localized (lacunar) stroke, but she is a little young, and would have to have an extremely high blood pressure. Trouble in the spinal cord would probably be bilateral and associated with distal (leg/trunk) weakness, or be associated with pain. Any systemic disease like Myasthenia gravis (an autoimmune disorder of the motor end plates which is rare, but common enough to afflict at least one net.med reader) or Heavy Metal Poisoning or B6 overdose or B12 deficiency, or most common, Diabetes would probably present globally, not localized to one hand. Diabetic mononeuropathy (as opposed to poly-) does occur rarely, but would be part of a spectrum of symptoms associated with Diabetes. (Polyneuropathy on the other hand is very common if the diabetes is not properly controlled.) In this respect, since we know the problem is in right hand, the best place to start the neurologic exam is either in the LEFT hand, or the left FOOT. Verifying that these are normal would eliminate a lot. Out of the central Nervous system, we have the peripheral nerves, and the most common cause of localized damage to them is trauma or inflammation. So the next question is: where is the problem? Right hand. Does it extend up the arm? (No). There was trouble holding a pencil, you say. How do you hold a pencil? (Two fingers and the thumb) The missing symptom: those fingers and that thumb are numb - when comparing a pin-prick to the opposite hand. (The patient should close their eyes for this, otherwise they cheat.) Well, that makes the diagnosis. Now if I had phrased the case, "a menopausal woman comes into your office with localized sensory loss in the right median nerve distribution" you would have said, "That's obvious." But patient's don't do that, they come in complaining of dropped dishes and pencils, and if they do come in complaining of median nerve dysfunction, the odds are they don't have it, although you had better ask how they got such a notion. Their child the doctor is probably a more reliable source than a friend of their neighbor who just had a similar problem. The diagnosis: Median Nerve compression, also called Carpel Tunnel Syndrome - because the Median nerve travels through the sheath (tunnel) of the carpel (latin for wrist) synovium (lining of a joint). The median nerve is responsible for the Sensory aspects of the the front of the thumb and adjacent 2 1/2 fingers, the Ulnar is responsible for the little finger and adjacent 1/2. The Radial nerve covers the back of the hand but not the nailbed. Only the Median nerve travels inside the synovial sheath, the others are outside and cannot be similary compressed. The compression occurs when the synovium becomes inflammed, either due to injury, or non-specifically. The latter type occurs most often in women, and is especially frequent during pregnancy and menopause. -- Craig Werner (MD/PhD '91) !philabs!aecom!werner (1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517) "Coke is much more socially acceptable than self-mutilation."