werner@aecom.UUCP (Craig Werner) (11/02/86)
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Medical Puzzle #11
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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?
.bp
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?
[(*) The passage of time fades the memory of the joke in question,
which was something like:
One morning, a girl walks up to a bank teller and deposits a
$50 bill in her account. The teller examines the bill and walks
back to her supervisor, and after a few minutes, comes back to
the window and says, "I'm sorry, but we can't accept this bill.
It's counterfeit."
"Oh my God," says the girl, "I've been raped."
Now, someone who didn't get the joke posted a long tirade against
this joke as offensive to women, others joined in in support. Still others
then tried to "improve" the joke, suggesting replacing 'girl' with
'woman', or just breaking the ultimate net.jokes rule - offering explanation.
Then the counteroffensive began, as dozens of people began
criticizing the flamers as misunderstanding the franchise of net.jokes,
and it then degenerated into long philosophical discussions over the
offensibility of jokes. Hundreds of kilobytes and hundreds of dollars of
phone transmissions later, it eventually died down. Anyway, that is why
the obscure reference to a $50 bill instead of just saying that she was
a prostitute.]
.bp
Medical Puzzle #13
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A 62-yr old white woman whose husband just recently retired comes in
complaining of weakness and fatigue. On appearance she is slightly overweight
but not excessively so. She does however, look pale. On examination of the
conjuctiva (pinks of the eyes), they are found to be lacking in color,
confirming the impression of paleness.
A fingerstick blood smear examined in the office reveals small, light
Red Blood Cells (a microcytic, microchromic anemia.)
(Iron deficiency is suspected on the basis of the microscopic picture,
and a few blood tests are sent out. Several days later they come back with
low Serum Iron, low serum ferritin, and elevated Total Iron Binding Capacity,
exactly what you'd expect in a chronic Iron deficiency.) Of course, you don't
know that now, with the woman in your office. All you know is what the slide
looks like, coupled with the knowledge that undetected Thalassemia is unlikely,
hence you already suspect an Iron deficiency.
Well, back in the office, CRT-chair doctors, what do you now?
.bp
Medical Puzzle #14
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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?
.bp
Medical Puzzle #15
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[I'm not sure how much past 20 I'll be able to take this. I'm beginning to
run out of easy diseases, syndromes, and symptoms. If you have had, or
know someone who has had, a medical problem that you think is worthy of a
puzzle, please write me (posting it would be slightly counterproductive.)
Confidentiality will be preserved, unless you want credit, in which case,
full credit will be given.]
[P.S. Although posted followups are discouraged until after the answer is
posted, all letters, with guesses or not, will be graciously answered.]
<>
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?
.bp
Medical Puzzle #16
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A 62-year-old woman with a 100+ Pack-Year(*) history of Cigarette smoking
(*)(1 Pack Year equals 1 pack a day for year. So 2.5 packs/day for
forty years would be 100 pack-years. It is a very useful
measurement since most smoking damage tends to be cumulative.)
is a regular at the health clinic, seen periodically for complaints of
chest pain, intermittent claudication (leg pain - secondary to poor
circulation due to atherosclerosis), trouble breathing (chronic
obstructive pulmonary disease and emphysema), and osteoporosis.
She suddenly presents with a new problem. Her complaint is
"I can't see too good out of my right eye anymore." By her account, her
vision has gotten worse over the past month or so, particularly when
she is indoors.
On examination, you find that her visual acuity (eye chart)
has in fact not changed. However, her right eyelid is drooping, and
her pupil will not dilate in response to a dimming of the lights.
Her left eye is fine, by the way.
There is also a third symptom present that is difficult to
check for. (Extra credit will be given to the person who comes
up with that symptom and the Eponym given to the triad. Offer not
open to AECOM students.)
Given these three symptoms, the onset, and the history, answer the
following three questions:
1. What is the cause of the woman's symptoms?
2. What is the cause of the woman's symptoms?
3. What is the cause of the woman's symptoms?
.bp
Medical Puzzle #17
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For this puzzle I have to do some education before the fact. So, for
this puzzle you need to know the following:
1) Blood clotting has two pathways, the one that acts in absence of
open wounds (Intrinsic) and the one that acts when blood meets air (Extrinsic).
2) There are 13 factors. Among others, XII,VIII (Anti-Hemophilia),
and IX are part of Intrinsic. VII is Extrinsic. They converge and X,V,
II (Prothrombin) and I (Fibrinogen) are common pathway.
3) Factors II,VII,IX,X require Vitamin K.
4) All the Vitamin K factors plus Factor V and Fibrinogen are made
in the liver.
5) There are three methods of measuring blot clotting: Prothrombin
Time (PT), Partial Thromboplastin Time (PTT), and Bleeding Time. The
former are done in tests tubes, the last involves cutting the patient, and
meets with some resistance, and is not usually done. PT measures the
Extrinsic Pathway, PTT measures the Intrinsic. Bleeding Time, but not
PT/PTT is prolonged by Aspirin (and this is the reason, not greater efficacy,
why Tylenol (Acetominophen) and not Aspirin are given in the hospital).
Summary: Intrinsic (PTT), Factors 12,8,9 \
>--->Common 10,5,2,1
Extrinsic (PT), Factor 7 /
Vit.K: 2,7,9,10
Liver: 1,2,5,7,9,10
------------------------------------------------------------------------
Hope that you're still with me:
A 36-year old woman is admitted to the hospital for routine elective
surgery (a D&C - Dilation and Curretage).
Prior to the operation, the usual battery of blood tests is performed
and it is discovered that the patient has a prolonged PTT. The operation
is postponed and a Hematology specialist is consulted.
The rest of the routine pre-op blood test is normal. The patient's
white and red cell count is normal. She is slightly anemic, but within
normal limits. A Prothrombin Time (PT) is performed, and it too is
abnormal. A Bleeding Time is not performed due to recent ingestion of
Aspirin.
Medical history is unremarkable. The patient suffers from occasional
headaches from which she alternately takes Aspirin, Acetominophen, or
Ibuprofen. The woman works as an anesthesiologist at the admitting hospital.
She has given birth twice with no complications, and had her appendix
removed at age 22 with no sequelae (complications).
Individual factors are them tested, and the woman is found to
suffer from a Factor V deficiency. All others are within normal limits.
So, what I've told you, and a little bit of Sherlockian insight
should lead you to speculate what's wrong with the woman.
Any guesses? (Oh, it's something you surely know about.)
.bp
Medical Puzzle #18
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A 55 year old dairy farmer in the New York City vicinity
(let's call him Farmer Bob) is inspecting his herd on a chilly
spring morning. Walking the perimeter of his farm, about 3/4
through the walk, he starts feeling faint and light-headed, and
collapses. He collapses, as it turns out, into the fence that
surrounds his farm, and which is electrified with a low power
current (*) to deter the cows from escaping. On the ground, he feels
a bit jolted from the unexpected contact with the electrified
fence, but otherwise OK, so he gets up off the ground, brushes
himself off, and shrugging his shoulders, continues on his way.
(*) Actually the fence is low amperage/high voltage frequent
short-pulsed DC current, if that's any clearer.
A few days later, on a similarly nippy New York Spring
morning, at approximately the same location in the walk, he again
feels weak and light-headed. Practical man that he is, he turns
to the fence and touches it with both hands and releases, and
feels better again.
Of course, eventually he does visit a doctor with his
complaint, and the story of the case is eventually relayed to
John Wurzelmann, who relays it to me, who is relaying it to you.
Oh I should add one more detail: let's just assume (and it's
a reasonable assumption) that Farmer Bob had Strep throat at some
point in his childhood, and that there might have been complications.
(after all, his childhood would be in the pre-antibiotic era.)
Questions:
1. What ails Farmer Bob?
2. Why does touching the fence help?
.bp
Medical Puzzle #19
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I'll admit that this one is difficult if not impossible without
any medical training. But it's a good story...
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?
.bp
Medical Puzzle #20
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A 17 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:
1) What are the two common syndromes that fit the symptoms?
2) Which one do you think that the doctor picked first, and
why do you think he did so?
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.
--
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."