"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow
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Workouts by month - Goal 200 from 11/1/09 through 10/31/10
http://ow.ly/1mYi7 - ABIM MOC program - two differing viewpoints - you can guess my voteMarch 16, 2010 5:06
RT @yejnes: My thoughts on the annual exam, etc., final letter ACP Internist, March 2010 http://bit.ly/9FNcXn wel-stated & importantMarch 15, 2010 12:47
A note to the professors, from the "real" world, on the use of ICDs in a fee for service community... http://ow.ly/1jaPy - great postMarch 13, 2010 2:19
RT @paulinechen: New "Doctor and Patient"; Learning to Keep Patients Safe in a Culture of Fear http://nyti.ms/bYA14V - blog post comingMarch 12, 2010 1:35
RT @tom_peters: @kevinmd Spoken like an MD. - true primary care is very complex - it is not simple care -March 11, 2010 12:43
RT @efalchuk: Seriously, what is Nancy Pelosi Talking About? http://bit.ly/9sHSc2 #healthreform #hcr #healthcare think Dazed and ConfusedMarch 10, 2010 7:53
Obama Says Health Overhaul Should Trump Politics - http://nyti.ms/bwKRyo - and he is correctMarch 8, 2010 7:28
@BertDecker multiples of 37 - trivial - any factor of 111 would factor into the others. The key here is that 37 * 3 = 111March 7, 2010 9:00
Here is a puzzle for you to consider. One of my residents told me that I needed to post more clnical problems.
Patient is 28-year-old white male with new jaundice. His only significant medical history is a 6-month history of grand mal seizures with a normal head CT.
He has noticed pale stools and dark urine for 3 days. He complains of epigastric pain.
Social history – previous work as an EMT ambulance worker. Had significant blood exposure 6 months ago (saved the life of a woman who jumped out of window).
His exam was remarkable for jaundice and a slightly enlarged liver.
Lab tests:
Normal CBC, normal basic metabolic panel
Liver tests
Destruction
Obstruction
Factory
AST
966
alk phos
188
albumin
3.9
ALT
1784
T. Bili.
7.5
INR
1.1
Direct bilirubin – 5.8
Your job:
construct a differential diagnosis and make your best guess for the correct answer. We do know the answer.
I’m going to guess gallstones. Abdominal CT or sonography to confirm. Please be kind to my guess by the way, I’m in my 3rd year of a 6 year med program and I have not taken laboratory diagnosis.
Pt’s enzymes c/w icteric phase hepatitis (despite elevated dbili, overall picture is more suggestive of hepatocellular damage); with seizures makes me think about Wilson’s disease. Blood exposure suggests the usual stuff. Dilantin a good thought, though you’re still left trying to explain the new seizures. Can get a post-ictal fulminant hepatitis. I guess should also think about alcohol, though that wouldn’t really explain chronic seizures, and ALT/AST pattern is wrong. Would get the usual hep stuff (infectious panels, tylenol), ceruloplasmin, dilantin level (if he’s on it). Second line – autoimmune stuff, ferritin, HIV. Awaiting smarter people.
Differential Diagnosis. Diff-er-en-ti-al Di-a-gno-sis. Hmm. Can’t say I’ve heard of the term before. What is it?
The boy be blocked. Get pictures, call GI or surgery, send upstairs. Next!
If you want to be fancy, I might suggest that the malignancy blocking his CBD may have a brain met causing the seizures. But that’s super speculative….
Has he been taking anything for the seizures? The values seem suggestive of biliary obstruction rather than than an infectious process or toxicity, but never hurts to ask. He could have been having a malignancy for the last six months that has been causing the seizures that just now caused a blockage.
7 Responses to A jaundiced man
John
January 27th, 2009 at 2:44 pm
I’m going to guess gallstones. Abdominal CT or sonography to confirm. Please be kind to my guess by the way, I’m in my 3rd year of a 6 year med program and I have not taken laboratory diagnosis.
david
January 27th, 2009 at 3:18 pm
dilantin induced hepatitis
Grant
January 27th, 2009 at 5:58 pm
hep c?
alexa-blue
January 27th, 2009 at 7:38 pm
Pt’s enzymes c/w icteric phase hepatitis (despite elevated dbili, overall picture is more suggestive of hepatocellular damage); with seizures makes me think about Wilson’s disease. Blood exposure suggests the usual stuff. Dilantin a good thought, though you’re still left trying to explain the new seizures. Can get a post-ictal fulminant hepatitis. I guess should also think about alcohol, though that wouldn’t really explain chronic seizures, and ALT/AST pattern is wrong. Would get the usual hep stuff (infectious panels, tylenol), ceruloplasmin, dilantin level (if he’s on it). Second line – autoimmune stuff, ferritin, HIV. Awaiting smarter people.
Mogi
January 27th, 2009 at 10:54 pm
The coincident onset of the seizures and exposure suggest an infectious etiology, such as an unusual presentation of HCV or HIV?
shadowfax
January 28th, 2009 at 1:58 am
Differential Diagnosis. Diff-er-en-ti-al Di-a-gno-sis. Hmm. Can’t say I’ve heard of the term before. What is it?
The boy be blocked. Get pictures, call GI or surgery, send upstairs. Next!
If you want to be fancy, I might suggest that the malignancy blocking his CBD may have a brain met causing the seizures. But that’s super speculative….
Number Seven
January 28th, 2009 at 1:26 pm
Has he been taking anything for the seizures? The values seem suggestive of biliary obstruction rather than than an infectious process or toxicity, but never hurts to ask. He could have been having a malignancy for the last six months that has been causing the seizures that just now caused a blockage.