Sunday, December 12, 2010

A Case from the ER... (part 1)


This X-ray is not diagnostic, but it is not normal. All you old school docs out there give me your thoughts after you hear this. This X-ray belongs to a really nice guy who's fifty years old. He came in to see me in the ER at the insistence of his family. He is holding a pillow under his right arm up against his flank. He hurts but does not have a surgical abdomen. As you form your differential please tell me what the most important part of this purposefully obtuse and incomplete history was. More to follow. Questions about the case answered as soon as I see 'em.

35 comments:

  1. SO, why does he have such a big liver? Hepatic abscess? From what?

    GruntDoc

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  2. I thought hearts were smaller than that. I guess it really is crowded in there. :)

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  3. Oh, the "What am I thinking?" Game!!!

    Well first of all, this X-ray is obviously an inadequate portable film, its rotated 2 degrees to the left, under penetrated, I mean over penetrated, OK, I might as well be tryin to read Chinese Calculus, but I'll spit out a differential...Ummm one question..
    What is this "History" of which you speak?

    1: PsudeoPsuedoHyperparathyroidism
    2: Kuru
    3: Carcinoid
    4: Type IIIa Membranoproliferativeproliferativemebranoi-itis
    5: Some liver thingie
    and sounds like that guy who died of a PE back in 1999, I mean 1989, after I told him to suck it up and stop bothering me...
    theoretically anyway.

    Frank

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  4. Where does he hurt? Do lungs sound clear?

    I'm going to shoot from the hip with carcinoid metastases. But, again, just a first-year.


    --MS1

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  5. Also, what made his family bring him in? New-onset pain? Shortness of breath?

    ...Jaundice? (Crosses fingers)

    --MS1

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  6. His liver is ginormous (that's a technical term).

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  7. The most important thing in the history is that he's a really nice guy. Nice guys get bad diseases. He's got cancer and it's everywhere - liver, lungs, probably brain.

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  8. and CholeraJoe gets the question about the most important part of the history right...

    further history... looks like casper the ghost (and the patient is caucasian), been to a naturopath who told him he had gallstones... and, he says that for the last year it 'feels like i've had a brick in my butt'.

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  9. Well it is either a big right sided abdominal mass or tremendous ascites. If you actually didn't have a CT you could figure out if it is a liver mass or ascites with ultrasound, or you could do a standing upright abdomen and see if drops away from the liver.
    The positive nice guy sign gives him a terrible prognosis. If he did something at triage like insist a crying child be triaged before him he will almost certainly die on your shift.
    Finally I think Drackman should get paid for the waffling read he provided for the film: 'an inadequate portable film rotated to the left'. Bravo sir, those are the words of a true expert, or at least thats how most rads I know like to read 'em.

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  10. dr j,
    he didn't have insurance or much money but gave all he had in his wallet to a small child in an iron lung... does that count?

    drackman should have been a radiologist... no, a urologist... dick jokes all day...

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  11. further hisotry... recent visits to various versions of health departments and urgent care clinics produced prescriptions for 'bronchitis' which did not clear up his symptoms....

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  12. Metastatic small cell lung cancer originating from the right bronchus?

    --MS1

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  13. dear MS1,
    ah, i remember those heady days when getting the right diagnosis was so cool! that's not the diagnosis... this case is more of a forrest than a tree case.

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  14. Purposefully obtuse and incomplete history...sex? Drugs? Rock and roll?

    Hot or cold?

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  15. purposefully obtuse and incomplete because the last time i did one of these cases from the ER the answer was malaria and the diagnosis was made on the first comment! didn't get to feel all important like the docs at grand rounds....

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  16. he looked anemic... pale conjunctivae... bold palmar creases... pulse sinus at 135 upon arrival... t and x 2uprbcs and i told him i would probably be giving him a transfusion... some dark tarry stools two weeks ago...

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  17. Our guy has a congenital abnormality that often will show in liver/bowel/diaphragm weirdness etc. (not a surgical abdomen?) And, he's got cancer or some consequence of his abnormal bowel.

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  18. ... and I'll add to my post above... or leukemia?
    - SCRN

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  19. Schistosomiasis and bladder cancer.

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  20. Biliary obstructing gallstone causing ascites, jaundice, and GI bleed? The dyspnea is secondary to hepatic encephalopathy that is restricting proper inspiration?

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  21. that is the cause of being smoked., and drinkn' alcoholic.., i think that is colon cancer.

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  22. DILATED BOWEL, BIG LIVER, A LUNG MASS AND A BRICK IN HIS ASS = METASTATIC RECTAL CANCER

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  23. gaucher's disease

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  24. anonymous...
    WHEN YOU TYPE IN ALL CAPS ITS LIKE YOUR YELLING>! AND MAYBE HE JUST HAS A NATURALLY BIG LIVER< SEE DAMMIT< IM TYPING > INSTEAD OF ! LIKE I WANTED< DAMMIT!! AND YOUR BOWELS ARE SUPPOSED TO DILATE< DAMMIT AGAIN< AND I DONT SEE NO LUNG MASS< AND MAYBE HE LIKES HAVING BRICKS UP HIS ASS

    idiot,

    Frank

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  25. Colorectal CA with mets, hepatocellular carcinoma, sarcoidosis, hemolytic anemia (immune or non-immune?), pernicious anemia/B12 deficiency

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  26. alkaline phosphatase 789, other labs remarkably normal...

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  27. Hepatitis C secondary to either a tattoo or remote IV drug use

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  28. I'd check a CEA...
    umm do they even test for CEA these days? Last time I checked one, ummm HEARD about someone checking one, I hadn't even ripped the plastic off my spankin brand new copy of Deep Throat...
    I'd bet it's higher than the National Debt...

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  29. hot/cold? redlight/greenlight?
    -SCRN

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  30. What is sad is that I am reading the comments and he seems to have gone to the doctor and tried to figure this out only to be sent away with smaller diagnoses and treatment for those. I have no idea what he has, but it's sad that he didn't get help earlier. It's sad that his niceness is probably what made this worse because he probably just believed whatever the doctor said and tried to just deal with it.

    I know there are a lot of pain in the ass whiney patients, but for every one of them there is one like him or me who don't want to be a bother and potentially leave something linger because the doctor hasn't really found much. I was willing to live with the pain from that thing in my head because my doctor didn't really seem to be finding anything and started offering me pain meds, which I did not want (and figured I was on my way to "crazy patient", a place I didn't want to go). If he hadn't known me I would have been screwed. And I would have walked away and just dealt with the pain rather than going anywhere else because he said nothing was wrong.

    My question in this is how do you guys tell the difference? I never really act like I'm in pain and don't really push for anything because I don't want to make a big deal out of anything. How does a patient avoid being overlooked when something serious is going on?

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  31. And also? Do I win for longest comment ever? Sorry about that!

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  32. hey radgirl! how are you doing? love the comment... long but great... and so unlike frank's comments which are all set-ups for set-ups for rants or jokes... that's why i love him....

    all of you diagnosticians are possible correct... post to follow shortly...

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  33. Well, if it's not ischemic bowel then I give up and my final diagnosis will be necrotizing fibromyalgia.....

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