So You Think You Can Diagnose? Vol. 2

On May 24, 2010, in SYTYCD, by NYIT College of Osteopathic Medicine SGA

By: Eric Steinberg, OMS III

Alright NYCOM, time to test what you have learned so far. The following clinical vignettes are all extremely high-yield for your Step 1.  If you get all five correct, I will give you a hug.  You have carpeted lecture halls…no excuses!!!

  1. 1. A toddler slowly develops eczema, seizures, and mental delays
  2. 2. Several children from the same school show up to the ER with high fever, stomach pains, and rashes with rose-colored spots on their stomachs.
  3. 3. A couple living on a houseboat present with flu-like symptoms, but guess what, they don’t have the flu.
  4. 4. An obese alcoholic male presents to the ER with a red, excruciatingly painful toe joint
  5. 5. A cave explorer presents to your office with dyspnea and hemoptysis. He is wearing a Cleveland Browns hat and a Cincinnati Reds jersey.

Answers…

  1. Phenylketonuria (PKU) is an inherited toxic buildup of the chemical phenylalanine due to the deficiency of the hepatic enzyme phenylalanine hydroxylase.  Lowering of phenylalanine levels to a safe range may be achieved by combining a low phenylalanine-diet with protein supplements.  PKU is generally detected through newborn screening and diagnosed by a geneticist.
  2. Typhoid fever, common worldwide, is transmitted by the ingestion of food or water contaminated with feces from an infected person. The bacteria then perforate through the intestinal wall and are phagocytosed by macrophages. Salmonella Typhi, more correctly called Salmonella enterica enterica Typhi, then alters its structure to resist destruction and allow them to exist within the macrophage. This renders them resistant to damage by PMN‘s, complement and the immune response. The organism is then spread via the lymphatics while inside the macrophages. This gives them access to the reticuloendothelial system and then to the different organs throughout the body. The organism is a Gram-negative bacillus that is motile due to its flagella. Typhoid fever is characterized by a slowly progressive fever as high as 40 °C (104 °F), profuse sweating, gastroenteritis, and non-bloody diarrhea. Less commonly a rash of flat, rose-colored spots may appear (COMLEX buzz-word). Treat with a fluroquinolone such as Cipro.
  3. Carbon monoxide poisoning is a potentially fatal (and widely misdiagnosed) syndrome often presents in enclosed quarters powered by generators and space heaters. The main manifestations of poisoning develop in the organ systems most dependent on oxygen use, the central nervous system and the heart. Symptoms of acute carbon monoxide poisoning include headache, nausea, malaise, and fatigue. These symptoms are often mistaken for a virus such as influenza or other illnesses such as food poisoning or gastroenteritis. Headache is the most common symptom of acute carbon monoxide poisoning; it is often described as dull, frontal, and continuous.For COMLEX, make sure you know how it shifts the hemoglobin dissociation curve!
  4. Gout is a disease hallmarked by elevated levels of uric acid in the bloodstream. In this condition, crystals of monosodium urate, or uric acid, are deposited on the articular cartilage of joints, tendons, and surrounding tissues. It is marked by transient painful attacks of acute arthritis initiated by crystallization of urates within and about the joints and can eventually lead to chronic gouty arthritis and the deposition of masses of urates in joints and other sites, sometimes creating tophi. The first line of treatment for an acute attack should be pain relief.  The board likes an NSAID (ie indomethacin) for this.  And they like tricking you by listing other anti-gout drugs for long-term management of gout.  Know the MOA of these drugs as well (allopurinol and probenecid).
  5. Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. Symptoms of this infection vary greatly, but it primarily affects the lungs.  The acute phase is characterized by non-specific respiratory symptoms, often cough or flu-like. Chest X-ray findings are normal in 40–70% of cases Chronic histoplasmosis cases can resemble tuberculosis; disseminated histoplasmosis affects multiple organ systems and is fatal unless treated.  COMLEX likes you to know that it is endemic in certain areas of the United States, particularly in states bordering the Ohio River valley and the lower Mississippi River.  H. capsulatum grows in soil and material contaminated with bird or bat droppings (guanoooooo). The fungus has been found in poultry house litter, caves, areas harboring bats, and in bird roosts (particularly those of starlings). The fungus is thermally dimorphic: in the environment it grows as a brownish mycelium, whereas at body temperature (37°C in humans) it morphs into a yeast.  Treat with Amphotericin B.
 

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