I had a few interesting cases in the ER today, and I wanted to share them with you guys. When presented with the cases, my fellow students created a laundry list of scenarios, and only after some prodding and hints produced the 'correct' answer. However, when I asked a friend who is in an unrelated field he got them right either immediately or after a guess. I'm curious in general as to how people would approach these questions and answer them.

1.) Someone comes in with a chronic cough. When they go under a routine physical, they have absent heart sounds (heart sounds are listened to on the left), the right lung sounds muffled, and the liver cannot be felt (the liver is felt for on the right). What is one reason they have those findings on the physical?

2.) If someone has Parkinson's (they twitch alot essentially) with superimposed seizures (you know that drill), what complication do you think would arise that is directly caused by the action of both occuring at the same time? This complication can result in a fatality.

I wonder how y'all will do. It may prove a point about overthinking problems as well, heh. IMHO they answers are intuitive and you don't need medical training or familiarity to answer them.

Collapsed lung?


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Uh, snapped neck?

I should also mention, in the first case, that the lung finding was found from the back. Just to clear up for now, don't really think about the cough. It's related to what the guy has, but to make that connection you need to know some inane medical details.

No cigar on either of those answers spook.

1. They're really, really fat, and the lard is dampening the sound. The cough is just an unrelated bronchitis.

2. I'd say cardial problems, arrest maybe? Fibrillation?

Maybe it's just weird-*** common sense kind of things -- IE, the first one is reversed organs, and the second one is that people might not notice the seizure in time to do anything about it.

1.) They aren't fat

2.) Think about something simple, directly caused by the muscle activity. Although that is a good thought.

Heh, I think I'll stop giving hints on stuff for now, see if a consensus is formed.

1) Maybe the guy's got that mirrored organs condition (although I understand that's rather rare) and the muffled lung sound is related to his cough. To be honest it sounds like the whole physical is being performed on someone wearing something thick over their body.

2) Can you die of exhaustion or dehydration from that much twitching and moving? Is his breathing affected by this?

It was a joke.


Asphyxiation?

Lupus

[url]www.webmd.com[/url]

???

Isn't there a risk of choking on your own tongue with violent seizures? Is that it?

I'm curious. What unrelated field is your friend in? I have two guesses.

Eh, sorta unrelated. Psychology.

1.) Yea, a few got it with the mirrored organs: http://en.wikipedia.org/wiki/Situs_Inversus

The reason for the right lung sounding like it did was because the heart was there, heh.

2.) You know when you get a bad flu, or are just cold in general, what do you do? Shiver. The massive prolonged muscle relax/contract cycles the man was going through was giving him hyperthermia. I think he was like 105 when we saw him; 107 starts causing serious damage. The damage there would happen alot quicker than usual, because in parkinsons tremors stop with voluntary movement (or at least lessen). Here, no matter what he was shaking. Hyperthermia is a very rare complication of seizures, but with parkinsons added, it becomes a lot more likely.

Good ideas all around though. I mean, with #2, you guys were all right, it's just that hyperthermia becomes a real important problem that can almost overshadow the rest because it can spike quicky and can take a while to cool. Cooling measures are HORRIBLE too... dropping a person who feels freezing into a tub of ice.

Funny what LordVirus mentioned actually happened: the parkinsons was masking the seizures. The primary care guy was just putting him on parkinson's drugs (basically dopamine) and the wife couldn't tell the difference. In any case, good show.



Heh, maybe so, but that is like the most common reason for both not feeling or hearing a structure. It can present the same way, heh.



lol, yes, that Diabetes, HIV, and I think Hypertension are general crap you can put on almost every differential because they cause everything...