Transcript peiris-copeland-final

Clinical cases from antiquity to the 21st
Century
AKA : Halloween Tales of black urine, green blood
Alan N. Peiris MD(London), MRCP(UK)
Chief of Endocrinology, Mountain Home VAMC
Professor of Medicine, ETSU
Rebecca Copeland MD, FACP
Associate Professor
Division Chief, Internal Medicine, ETSU
Case Bibliography by Hakam Khazrik MD
PGY-1 Internal Medicine
Has the era of the “Triple
Threat” Physician gone ?
• Anne Holmes FRCP
• Charles Wells FRCP
• EllIs Samols FRCP
• Sir John Richardson MD, FRCP
Venturing into the world of Spot Diagnosis
a) Common Manfestations of Common diseases
b) Uncommon Manifestations of Common diseases
c)
Common Manifestations of Uncommon diseases
d)Uncommon manifestations of uncommon diseases
Lloyd-Luke , London. (1984)
211 pages. Price £9.00.
(Out of Print)
Diagnosis and etiology ?
Winged Scapula
A lesion involving long thoracic nerve with resultant weakness in the
serratus anterior muscle.
Varying causes including trauma, heavy weight lifting, viral illness,
idiopathic.
Management may include nerve conduction studies, physiotherapy, and
possibly decompression
Diagnosis ?
Achondroplasia
ACHONDROPLASIA IS AN AUTOSOMAL
DOMINANT DISORDER OF BONE AND OCCURS IN
ONE IN 25,000 LIVE BIRTHS.
ACHONDROPLASIA IS THE MOST COMMON TYPE
OF DWARFISM, IN WHICH THE CHILD’S ARMS AND
LEGS ARE SHORT IN PROPORTION TO BODY
LENGTH.
ACHONDROPLASIA IS CAUSED BY MUTATIONS IN
THE FIBROBLAST GROWTH FACTOR RECEPTOR-3
(FGFR3) GENE.
Spock in Hospital ?
Doctors came across something
highly illogical when they tried to
put an arterial line into a patient
about to undergo surgery: his
blood was dark green. The green
blood — reminiscent of the Vulcan
blood found in Mr. Spock of Star
Trek fame . Diagnosis ?
What is the reason for the green
blood found in Vulcans according
to star trek lore ?
Additional lab studies ruled out methemoglobinemia,.
The next day, the lab reported it had detected
sulfhemoglobin, a condition thought to be triggered by
some medications (large amounts of sumatriptan ?).
Some drugs donate a sulphur group that binds to the
hemoglobin molecule and prevents it from binding to
oxygen and gives it the green color."
Flexman AM et al, Lancet 2007;369:1972
According to Star Trek lore, Vulcans have green
blood because the oxidizing agent in their blood is
copper, and not iron.
RETINAL FINDINGS – DIAGNOSIS ?
Retinitis Pigmentosa
RETINITIS PIGMENTOSA IS AN OCULAR DISEASE
CHARACTERIZED BY NIGHT BLINDNESS, FIELD CONSTRICTION,
AND PIGMENTARY CHANGES IN THE RETINA.
THE LATTER MAY BE DESCRIBED AS HAVING A ‘BONE
CORPUSCLE’ APPEARANCE WITH A PERI-VASCULAR
DISTRIBUTION.
THE RODS ARE IMPACTED EARLY WITH LEGAL BLINDNESS
COMMON BY THE 5THDECADE OF LIFE.
MAY HAVE A GENETIC BASIS OR OCCUR SPORADICALLY.
TREATMENT IS DIFFICULT. VITAMIN A MAY SLOW
PROGRESSION.
EKG done after Clinical diagnosis
Dextrocardia
Patients with Dextrocardia are often undiagnosed
until they receive their first chest x-ray or ECG.
When you encounter patient with Dextrocardia, it is
important to place the left-limb leads on the right
side. If the leads are placed in their traditional
location, the ECG will show inverted P and T waves.
An alerting sign is a P and QRS inversion in lead 1.
If you encounter this, first check your limb leads to
assess proper placement.
The case of the calcified Mummy
• Roentgenograms of an
Egyptian mummy, dating
from 1500 B.C., showed
extensive calcification of
the intervertebral discs
and articular narrowing in
both hip and knee joints.
Biopsy cores from the
right hip showed parallel
black zones in the region
of the articular surfaces
Alkaptonuria - Ochronosis
The black pigment was extracted, analyzed, and
compared to an air-oxidized homogentistic acid
polymer. The two substances apparently were
identical. The chemical evidence thus confirms the
clinical finding of ochronosis, an autosomal recessive
disorder. Perhaps, the earliest verified case of this
disorder.
Biochemical identification of homogentisic acid pigment in an
ochronotic egyptian mummy. Stenn FF et al Science 5 August
1977: Vol. 197 no. 4303 pp. 566-568
Recurrent Pleural Effusions
• Patient also had
lymphedema
• Diagnosis ?
Yellow Nail syndrome
• Primary lymphedema associated with yellow
nails and pleural effusion
• Very rare medical syndrome that affects adults
and includes pleural effusions, lymphedema and
yellow dystrophic nails.
• Patients may also have bronchiectasis and
chronic sinusitis
Your thoughts ?
Plombage balls are
present in the left
upper lobe. The
patient was
diagnosed with
cavitary pulmonary
tuberculosis in 1945
underwent a
plombage procedure
in the late 1940s
Lucite balls for plombage therapy, used
until the 1950s.
43 yr old apparently healthy man admitted for observation after vehicular
injury. He undergoes uneventful splenectomy for splenic trauma. A nurse on
the floor seeks an informal consult for the following interesting sequence…
Apparently, 2 days after splenectomy he was found to be unresponsive with
profoundly hypoglycemia (lab glucose < 20 mg/dl). Patient was started on
dextrose drip but has remained unresponsive in an “vegetative” state even
though his glucose has normalized.
Systolic blood pressure high 90’s. Surgery is satisfied that it does not relate to
splenectomy. Serum cortisol, CBC, chem 18, coagulation parameters are all
appropriately normal. ABG reveals mild metabolic acidosis. Patient does not
have a history of Diabetes and was not on any medications pre-admission.
Name a few additional tests that you could order and can you make any
diagnostic or therapeutic suggestions?
Wernicke’s Encephalopathy
Sulfonylurea drug screen
Insulin, c-peptide and lab glucose
Urine drug screen
Give 100 mg IV thiamine immediately
MRI of Brain
Iatrogenic exacerbation of Wernicke
encephalopathy can occur with
prolonged glucose or carbohydrate
loading in the setting of thiamine
deficiency.
Erythrocyte transketolase levels
reliably detect thiamine deficiency but
are not necessary for the diagnosis of
Wernicke encephalopathy
Hypotension can be seen
Bonus question
Which former ETSU Chair wrote a
book about his clinical and life
experiences and how they may have
saved his life during a harrowing
kidnapping ?
What was the title of the book ?
Steven L. Berk MD
Former ETSU Chair in Internal
Medicine and Currently Dean
and Provost TTUHSC in
Lubbock
“ The Anatomy of a
kidnapping”.
Mycroft Holmes - The ultimate
Internist ?
“Possessing deductive powers exceeding even those of his
younger brother, Mycroft is nevertheless incapable of
performing detective work similar to that of Sherlock as he
is unwilling to put in the physical effort necessary to bring
cases to their conclusions.
Again and again I have taken a problem to him, and have
received an explanation which has afterwards proved to be the
correct one. And yet he was absolutely incapable of working
out the practical points” (or change to interventional
Procedures ?)
—Sherlock Holmes, speaking of his brother in "The Adventure
of the Greek Interpreter“
Source: Modified from Wikipedia, 2011
Name this British Medical School
where Sir Arthur Conan Doyle
describing the first meeting of
Sherlock Holmes and Doctor
Watson.
Notable Alumni include:
William Harvey - First person to
describe circulation
James Parkinson - first to describe
Parkinson's Disease
Sir James Paget - Surgeon and
founder of scientific medical
pathology
Percival Pott - English Surgeon,
founder of orthopaedics
The Medical College of St Bartholomew's
Hospital, London (the oldest remaining hospital in the
United Kingdom, having been founded in 1123, with
medical teaching beginning from that date).
It survived both the Great Fire of London, and the Blitz in
the Second World War. St Bart’s was also the site of the
execution of the Scottish patriot Sir William Wallace, and
there is a plaque on the hospital’s exterior wall near the
spot.
Quiz Interpretation
•You have failed to identify any of the conditions shown and you are
lost, bewildered, confused and a tad angry
Answer: You maybe at the wrong grand rounds
presentation ?
•You have correctly identified some of the conditions shown
Answer: You are at the right presentation. Well Done !
•You have identified all the conditions shown and are wondering when
will they bring out the “really hard” stuff?
Answer: You are at the right presentation and your name
is Dr J. Kelly Smith MD
• There is a rich history of medicine depicted in art dating
back to the cave drawings.
• The earliest written record of medical history and artistic
representation comes largely from the Egyptian papyri
and Mesopotamian clay tablets dating back only about
4000 years.
• There is a huge body of art and medicine from all
cultures including Far Eastern, Middle Eastern, and later
Western European civilizations.
• This presentation will be limited to examples of specific
or postulated medical diagnoses as rendered in art.
Trephined neolithic skull
Figure 1, pg 29, In: See Reference 1.
Cave drawings from El
Pindal cave in Spain
showing rudimentary
knowledge of circulatory
system
Figures 14,15, pg 23, In: Reference 2.
Ancient Peruvian pottery
showing amputation and
prosthesis
Figure 4, pg 33, In: Reference 1.
Mummified head of the
Pharaoh Ramses V. 1160
B.C., showing lesions
thought to be those of
smallpox
Figure 142, pg 92, In: Reference 2.
Young man leaning on staff
with withered leg
characteristic of polio
Figure 148, pg 95, In: Reference 2.
Example of Aztec cleft
palate
Figure 68, pg 49, In: Reference 2.
Pre-Columbian clay figure
showing effects of
elephantiasis
Figure 77, pg 52, In: Reference 2.
Clay figure of man with
pustules thought to
represent syphilis
Figure 82, pg 55, In: Reference 2.
Clay statue with Pott’s
disease
See reference 3.
Pott’s disease –
Tuberculosis of the spine
and psoas abscess
Figures 143,144, pg 93, In: Reference 2.
Congenital dislocation
of the hips
Reference 4.
Bas-relief showing early
Indian dentistry
nd
(2 Century B.C.)
Figure 166, pg 107, In: Reference 2.
“The First Nose Jobs.”
Pg 17, In: Reference 5.
Schematic drawing of
surgical technique for nose
job by using a flap from the
forehead
Figure 184, pg 114, In: Reference 2.
Cast of Chinese woman’s
bound foot showing
compression of the arch
and folding under of toes
which was considered the
“ideal”
Figure 213, pg 138, In: Reference 2.
Drawing showing
comparison of bound and
normal foot
Figure 215, pg 139, In: Reference 2.
Greek Votive tablet showing
varicosities of the leg
Figure 264, pg 173, In: Reference 2.
Tombstone of the Athenian
nd
physician, Jason (2
Century B.C.) palpating the
abdomen
Figure 301, pg 201, In: Reference 2.
Skeleton from Persian
manuscript
Pg 62, In: Reference 6.
th
14
Skeleton from a
Century Latin Munich
manuscript
Pg 69, In: Reference 6.
Leonardo da Vinci
Renaissance Man
Pg 103, In: Reference 6.
Andreas Vesalius
Renaissance Man
Pg 179, In: Reference 6.
Black Death from the
Toggenburg Bible
Reference 7.
Cataract Surgery done by
Arabic physician –
technique by displacing the
opaque lens down from the
line of vision
Figure 458, pg 308, In: Reference 2.
The technique of reducing a
complete dislocation of the
shoulder.
Figure 588, pg 384, In: Reference 2.
Diffuse goiter of the right
lobe of the thyroid
Reference 8.
Exophthalmos of Saint
Monica
Michelangelo’s Last
Judgement
Reference 9.
Van Gogh
The Starry Night
Reference 10.
Van Gogh’s Physician with
foxglove plant
Pg 175, In: Reference 11.
“The Blurry World of Claude
Monet Recreated”Computer simulated estimation
by Stanford ophthalmologist,
Michael Marmor, of the critical
degree of Monet’s visual
impairment secondary to
cataracts
Reference 12.
References
1. Ackerknecht EH, A Short History of Medicine. New York: The Ronald Press
Company; 1968.
2. Lyons AS, Petrucelli II RJ. Medicine: An Illustrated History. New York: Harry
N. Abrams, Incorporated; 1978.
3. Clay statue with pott’s disease. Tuberculosis By M. Monir Madkour.
http://books.google.com/books?id=iWnwrHy3uF0C&pg=PA5&dq=clay+statu
es+with+potts+disease&source=bl&ots=45ujjX6bYh&sig=RDKK0CIH9MP4k
TuwOryDlqkPIAo&hl=en&ei=E0ywTqKpFMq5tgeuLX&sa=X&oi=book_result&ct=results&resnum=2&ved=0CCUQ6AEwAQ#v
=onepage&q&f=false. Accessed November 2, 2011.
4. Aches and ills of the ancient. Madame Pickwick Art Blog.
http://madamepickwickartblog.com/2011/07/aches-and-ills-of-the-ancients/.
Updated July 8, 2011, Accessed October 31, 2011.
5. Sutcliffe J, Duin N, A History of Medicine. New York: Barnes & Noble
Incorporated; 1992.
6. Choulant L, History and Bibliography of Anatomic Illustration. New York:
Hafner Publishing Company; 1962.
References Continued
7. Black Death. Wikipedia, the free encyclopedia.
http://en.wikipedia.org/wiki/Black_Death. Updated October 28, 2011.
Accessed November 11, 2011.
8. Byzantine. Goiter depicted in Byzantine artworks by Laszlo G. Jozsa.
http://byzantineee.blogspot.com/2011/03/goiter-depicted-in-byzantineartworks.html. Updated March 7, 2011. Accessed November 2, 2011.
9. Blessed with exophthalmos in Michelangelo’s Last Judgement. Oxford
Journals Medicine QJM.
http://qjmed.oxfordjournals.org/content/96/9/688.1.full. Updated 2003.
Accessed November 2, 2011.
10. “Starry Night” by Vincent Van Gogh. Painting. Oil on Canvas.
http://www.vangoghgallery.com/catalog/Painting/508/Starry-Night.html.
2011. Accessed November 3, 2011.
11. Wallace R, The World of Van Gogh 1853-1890. New York: Time-Life
Books; 1969.
12. The Blurry World of Claude Monet Recreated. LiveScience.
http://www.livescience.com/1512-blurry-world-claude-monet-recreated.html.
Updated May 11, 2007. Accessed November 7, 2011.