Think like a doctor

[jippyslim]

I know we are just premeds, but...

I normally check out the Think Like a Doctor series on the The NY Times' Well Blog. They always present some interesting actual cases and ask readers what they think the diagnosis is. I don't understand all the material, but it is interesting to see the thought process of the physicians as they try to come up with the diagnosis.

Does anyone else check this out?


Here's the link to this week's case. Think you can come up with the diagnosis?: http://well.blogs.nytimes.com/2012/04/05/think-like-a-doctor-a-crooked-walk/

I'll post the answer tomorrow when the Times releases the correct answer.

P.S If you are not a Times subscriber and have gone through all your free articles for the month you will not be able to view the article. I could post it here, but it'd be pretty long.

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[Morsetlis]

That's like saying

"Think like a computer scientist:
Lemma. Let ϕ be a propositional Horn-formula. Let Y denote the set of atoms which are obtained by initializing Y to the set of facts in ϕ and by exhaustively applying the rules in ϕ to Y . Then, for every atom x in ϕ, the following equivalence holds: x ∈ Y ⇔ x is
implied by the facts and rules in ϕ.
Give a rigorous proof of this lemma."

No, it's just edutainment. If you don't understand the pieces, you won't learn anything from "solving" the puzzle. And even iff you do, not having a clinical scenario or a concrete event to associate the learning with means you will forget it soon afterward.

 

[jippyslim]

That's like saying

"Think like a computer scientist:
Lemma. Let ϕ be a propositional Horn-formula. Let Y denote the set of atoms which are obtained by initializing Y to the set of facts in ϕ and by exhaustively applying the rules in ϕ to Y . Then, for every atom x in ϕ, the following equivalence holds: x ∈ Y ⇔ x is
implied by the facts and rules in ϕ.
Give a rigorous proof of this lemma."

No, it's just edutainment. If you don't understand the pieces, you won't learn anything from "solving" the puzzle. And even iff you do, not having a clinical scenario or a concrete event to associate the learning with means you will forget it soon afterward.

Poppycock. Your logic analogy doesn't appeal to me, what's in the article does.

As I said before, I do not have an understanding of/haven't been exposed to all the pieces in the cases (because i'm only a lowly premed) but I do get to see what physicians actually do in order to diagnose a disease, which is something I intend to do later. Is that such a bad thing? I don't think so.

 

[N2Medicine]

Poppycock. While your logic analogy doesn't appeal to me, what's in the article does.

As I said before, I do not have an understanding of/haven't been exposed to all the pieces in the cases (because i'm only a lowly premed) I do get to see what physicians actually do in order to diagnose a disease, which is something I intend to do later. Is that such a bad thing? I don't think so.

Thanks for posting this. I'm enjoying reading the comments. My thought on the Dx is Peripheral Neuropathy. I'm not a doctor, so I'm just guessing. What do you think it is?

 

[ensuii]

lol

 

[TheMightySmiter]

I read it for entertainment, but it's pretty much useless to guess a diagnosis unless you have an MD. The people who get the correct answers are usually seasoned attending who happen to have seen a similar case before.

 

[mmmcdowe]

Thanks for posting this. I'm enjoying reading the comments. My thought on the Dx is Peripheral Neuropathy. I'm not a doctor, so I'm just guessing. What do you think it is?

Peripheral neuropathy really isn't a diagnosis. It's just a classification of diagnoses related to nerve problems outside the central nervous system.

At first based on the history and age I was thinking Mystenthia Gravis or Lambert Eaton, but they don't really give enough detail in terms of her symptoms and signs to support that. Also, I can't remember how to read for those on an EMG . Her exam made with think of a female expression of becker's muscular dystrophy (the way it was phrased was similar to Gower's sign, though not equivalent), but they didn't find further evidence. The possibility of a compressive mass in the spinal cord was ruled out. ALS sounded good but wasn't consistent with her exam. SMA sounds good, but I am unsure if this article likes to pick situations in which the doctor is wrong? Her radiographic findings made me think of something like a Chiari malformation, Friedriech's ataxia, or Dandy-Walker Syndrome, but neither really is consistent with the clinical or radiographic findings on second look.

 

[N2Medicine]

I read it for entertainment, but it's pretty much useless to guess a diagnosis unless you have an MD. The people who get the correct answers are usually seasoned attending who happen to have seen a similar case before.

Why not guess? The whole idea of the series is to guess what you think the diagnosis is. If you are right or wrong, who cares? Apparently the case has already been solved, so the comments really mean nothing.

 

[mmmcdowe]

Why not guess? The whole idea of the series is to guess what you think the diagnosis is. If you are right or wrong, who cares? Apparently the case has already been solved, so the comments really mean nothing.

I agree. It's always fun to guess. If your interested enough to guess, you're likely interested enough to learn and that's the whole point of this.

 

[N2Medicine]

I agree. It's always fun to guess. If your interested enough to guess, you're likely interested enough to learn and that's the whole point of this.

Exactly. I'm not die-hard researching for the answer. I'm using Google and seeing what I think sort of fits. It is harmless and gives a bit of insight into cases that doctors actually do get sometimes.

Peripheral neuropathy isn't a diagnosis. It's just a classification of diagnoses related to nerve problems outside the central nervous system.

At first based on the history and age I was thinking Mystenthia Gravis or Lambert Eaton, but they don't really give enough detail in terms of her symptoms and signs to support that. Also, I can't remember how to read for those on an EMG . Her exam made with think of a female expression of becker's muscular dystrophy (the way it was phrased was similar to Gower's sign, though not equivalent), but they didn't find further evidence. The possibility of a compressive mass in the spinal cord was ruled out. ALS sounded good but wasn't consistent with her exam. SMA sounds good, but I am unsure if this article likes to pick situations in which the doctor is wrong? Her radiographic findings made me think of something like a Chiari malformation, Friedriech's ataxia, or Dandy-Walker Syndrome, but neither really is consistent with the clinical or radiographic findings on second look.

All of the diseases you mentioned have been in the comments. I hope one of them is right. I was also thinking Lyme disease. I know the tests said negative, but I read a few minutes ago that the test for Lyme disease isn't that accurate. The leg weakness made me think of an episode of House where a girl presents with difficulty climbing stairs. Her final diagnosis was Lyme disease, but it is a TV show; not a very reliable source of evidence to one condition or another.

 

[mmmcdowe]

Exactly. I'm not die-hard researching for the answer. I'm using Google and seeing what I think sort of fits. It is harmless and gives a bit of insight into cases that doctors actually do get sometimes.



All of the diseases you mentioned have been in the comments. I hope one of them is right. I was also thinking Lyme disease. I know the tests said negative, but I read a few minutes ago that the test for Lyme disease isn't that accurate. The leg weakness made me think of an episode of House where a girl presents with difficulty climbing stairs. Her final diagnosis was Lyme disease, but it is a TV show; not a very reliable source of evidence to one condition or another.

You never know, House cases are often based on actual cases. It seems pretty lame though to give no history of lyme risk factors PLUS a negative lyme test (CSF and serum it sounded like). Plus chronic lyme tends to have some other symptoms besides neuropathy.

 

[N2Medicine]

You never know, House cases are often based on actual cases. It seems pretty lame though to give no history of lyme risk factors PLUS a negative lyme test (CSF and serum it sounded like). Plus chronic lyme tends to have some other symptoms besides neuropathy.

It says somewhere that the mother had lyme disease that went untreated while she was pregnant. Not sure if that could be spread to the child or not.

I looked up a few of the diseases you posted, and Myasthenia Gravis seems the most promising imo.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001731/

"Signs and tests

The health care provider performs a physical exam, including a detailed nervous system (neurological) examination. This may show:

Muscle weakness - eye muscles are usually affected first

Reflexes and feeling (sensation) are normal."

Besides the eye muscles being affected first, it is pretty consistent with the information on the page.

 

[sweet d]

The leg weakness made me think of an episode of House where a girl presents with difficulty climbing stairs. Her final diagnosis was Lyme disease, but it is a TV show; not a very reliable source of evidence to one condition or another.

Fun fact: author of this column is an advisor to the writers of House.

 

[jippyslim]

I read it for entertainment, but it's pretty much useless to guess a diagnosis unless you have an MD. The people who get the correct answers are usually seasoned attending who happen to have seen a similar case before.

This is true.

 

[jippyslim]

I agree. It's always fun to guess. If your interested enough to guess, you're likely interested enough to learn and that's the whole point of this.

 

[LizzyM]

If this were a PBL case and you were a medical student, you and your classmates would be in the library right now looking up things like differential diagnosis for leg weakness and fasciculations, the symptoms and course of congenital Lyme disease, how to interprete an EMG, the differential diagnosis of syndovial cysts,the post-test probability of Lyme disease in the face of a negative cerebro-spinal fluid test for Lyme, etc.

 

[ppfizenm]

past polio syndrome?

 

[jippyslim]

Thanks for posting this. I'm enjoying reading the comments. My thought on the Dx is Peripheral Neuropathy. I'm not a doctor, so I'm just guessing. What do you think it is?

I was thinking it was some form of Ataxia, based on some of the comments. Myasthenia gravis, after looking it up, sounds interesting.

Guess we'll find out tomorrow.

 

[N2Medicine]

I was thinking it was some form of Ataxia, based on some of the comments. Myasthenia gravis, after looking it up, seems to also be a possibility.

Guess we'll find out tomorrow.

I also looked up Myasthenia gravis. I think it has promise.

 

[mmmcdowe]

It says somewhere that the mother had lyme disease that went untreated while she was pregnant. Not sure if that could be spread to the child or not.

I looked up a few of the diseases you posted, and Myasthenia Gravis seems the most promising imo.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001731/

"Signs and tests

The health care provider performs a physical exam, including a detailed nervous system (neurological) examination. This may show:

Muscle weakness - eye muscles are usually affected first

Reflexes and feeling (sensation) are normal."

Besides the eye muscles being affected first, it is pretty consistent with the information on the page.

For MG what is missing is the temporal aspect. Things get worse throughout the day, etc.

As far as congenital Lyme, it would have appeared as a child (assuming such a thing exists, which is apparently debatable).

 

[ppfizenm]

I was thinking it was some form of Ataxia, based on some of the comments. Myasthenia gravis, after looking it up, sounds interesting.

Guess we'll find out tomorrow.

I also looked up Myasthenia gravis. I think it has promise.

she doesn't display any of the classic signs of Myasthenia gravis though. No eye involvement, no trouble swallowing, and at best a possible slurring of speech. Not to mention MG is usually episodic. I also don't see MG causing cerebellar atrophy.

 

[ensuii]

If this were a PBL case and you were a medical student, you and your classmates would be in the library right now looking up things like differential diagnosis for leg weakness and fasciculations, the symptoms and course of congenital Lyme disease, how to interprete an EMG, the differential diagnosis of syndovial cysts,the post-test probability of Lyme disease in the face of a negative cerebro-spinal fluid test for Lyme, etc.

...thank god I didn't do PBL.

 

[N2Medicine]

What do you all think of Creutzfeldt-Jakob disease?

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001792/

More likely than Myasthenia gravis?



I'm looking here for ideas:

http://www.ninds.nih.gov/disorders/cerebellar_degeneration/cerebellar_degeneration.htm

 

[mmmcdowe]

What do you all think of Creutzfeldt-Jakob disease?

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001792/

More likely than Myasthenia gravis?

Definitely not a prior disease. Much too slow and not enough crazy.

 

[ppfizenm]

What do you all think of Creutzfeldt-Jakob disease?

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001792/

More likely than Myasthenia gravis?



I'm looking here for ideas:

http://www.ninds.nih.gov/disorders/cerebellar_degeneration/cerebellar_degeneration.htm

Would have progressed much faster and effected mental abilities much more so than leading a doctor to believe she had a mild learning disability. This girl has been symptomatic for something like 7 years and people usually die after 8 months with this disease.

 

[mvenus929]

Thanks for posting this. I'm enjoying reading the comments. My thought on the Dx is Peripheral Neuropathy. I'm not a doctor, so I'm just guessing. What do you think it is?

What's causing the peripheral neuropathy, and why it is only affecting the neurons innervating the hip muscles? The lower leg muscles still have full strength. Also, there doesn't seem to be any sensory changes, which would point away from a straight peripheral neuropathy (since peripheral nerves are generally mixed nerves).

Fun fact: author of this column is an advisor to the writers of House.

Her book is also really good. It's one of the first medically related books I read when I was interested in med school.

For MG what is missing is the temporal aspect. Things get worse throughout the day, etc.

Agreed. Same with Lambert-Eaton that people keep suggesting... it tends to get better with activity, while MG gets worse. This doesn't seem to fit that pattern.

It's an interesting case, though.

 

[Morsetlis]

MG and LE tend to not be focal. A Gower's maneuver is associated with Duchenne's and Duchenne's is associated with X-inactivation and mosaicism in females. Duchenne's tend to cause elevation on the swing leg (Sup glut N / abductors of legs and gluteus med/min/TFL is L4-S1, Inf glut N / abductor of thigh / glut max is L5-S2).

It's true that MG EMG would be waning, while LE EMG would be waxing.

Neuro notes says "6mm extraspinal synovial cyst adjacent to the lateral aspect of the right facet joint at L4-5." Neuro initially diagnoses polyradiculopathy because of CHRONIC Lyme disease (neuroborreliosis) -_-

I guess we'll need to wait for the LP to find out, but at least it's not syphillis! -_-

Great learning, guys!

 

[mmmcdowe]

MG and LE tend to not be focal. A Gower's maneuver is associated with Duchenne's and Duchenne's is associated with X-inactivation and mosaicism in females. Duchenne's tend to cause elevation on the swing leg (Sup glut N / abductors of legs and gluteus med/min/TFL is L4-S1, Inf glut N / abductor of thigh / glut max is L5-S2).

It's true that MG EMG would be waning, while LE EMG would be waxing.

Neuro notes says "6mm extraspinal synovial cyst adjacent to the lateral aspect of the right facet joint at L4-5." Neuro initially diagnoses polyradiculopathy because of CHRONIC Lyme disease (neuroborreliosis) -_-

I guess we'll need to wait for the LP to find out, but at least it's not syphillis! -_-

Great learning, guys!

There was a LP and two separate lyme tests and lyme polyradiculopathy isn't motor specific typically.

 

[EvilSpawn]

Fun fact: author of this column is an advisor to the writers of House.

Therefore, it's Lupus

 

[Bacchus]

Didn't read beyond the first post, looking at article

Read this:

The Medical Mystery: Can you solve the case of a young woman with an odd gait and slowly progressive weakness in her hips and legs?

-Thinking muscular dystrophy-

Weakness in the hip and thigh muscles on both sides: She couldn't stand from a seated position unless she used her hands to push herself up; and when she walked on a level surface, her hips swung from side to side.

-Still thinking muscular dystrophy-

Tiny muscle twitches in the thighs, just beneath the skin — a symptom known as fasciculations.

-Some potential UMN signs, still thinking muscular dystrophy-

Oh, the special specialist also suggests spinal muscular atrophy.

I think its one of these two.

 

[Bacchus]

I went to elementary school with a girl that fits these symptoms, but younger --> waddling, leg swinging gait; progressive muscle weakness, etc. She's in a chair now and has Becker's MD.

 

[crazyasian]

This title makes me think of a book I recently read, "How Doctor's Think."

 

[calvnandhobbs68]

If this were a PBL case and you were a medical student, you and your classmates would be in the library right now looking up things like differential diagnosis for leg weakness and fasciculations, the symptoms and course of congenital Lyme disease, how to interprete an EMG, the differential diagnosis of syndovial cysts,the post-test probability of Lyme disease in the face of a negative cerebro-spinal fluid test for Lyme, etc.

Aka google the **** out of everything. Hooray for PBL.

 

[LizzyM]

Aka google the **** out of everything. Hooray for PBL.

I think "UpToDate.com" is the new Google.

 

[N2Medicine]

I don't think anyone posted the diagnosis on here. =/

http://well.blogs.nytimes.com/2012/04/06/think-like-a-doctor-a-crooked-walk-solved/

 

[ppfizenm]

I don't think anyone posted the diagnosis on here. =/

http://well.blogs.nytimes.com/2012/04/06/think-like-a-doctor-a-crooked-walk-solved/

Spoiler alert. If you click the link it will tell you.

People mentioned it in the comments.

 

[mmmcdowe]

I don't think anyone posted the diagnosis on here. =/

http://well.blogs.nytimes.com/2012/04/06/think-like-a-doctor-a-crooked-walk-solved/

Humm, I had seen that mentioned but it didn't seem to fit in my mind.

 

[KnuxNole]

...thank god I didn't do PBL.

Agreed. I would stab myself.

 

[jippyslim]

Humm, I had seen that mentioned but it didn't seem to fit in my mind.

It was fun looking up all the diseases that seemed to fit, though.

I checked the pubs to see what's new and found this bit. It seems an interesting read (based on the abstract) when it's actually published. I could pay $32, but i'll wait instead.

http://www.nature.com/mt/journal/vaop/ncurrent/full/mt201244a.html

 

[N2Medicine]

Spoiler alert. If you click the link it will tell you.

People mentioned it in the comments.

I think I should have rephrased. I meant that no one posted the answer in this thread and that you could find the answer by clicking on the link. Sorry about that.

 

[Bacchus]

I would have never guessed that! Of all the charts I've seen for the past ten months, I've seen one infant tested for a disease that would be similar.

Definitely a zebra.

 

[tima]

You can think like a doctor by putting on a white coat.

Mind Games: Sometimes a White Coat Isn't Just a White Coat
http://www.nytimes.com/2012/04/03/science/clothes-and-self-perception.html

 

[Morsetlis]

I would have never guessed that! Of all the charts I've seen for the past ten months, I've seen one infant tested for a disease that would be similar.

Definitely a zebra.

Oh, you mean we didn't get a fundoscopy and onion-shell inclusions on microscopy?

Turns out random charts isn't a good substitution for a physical exam.

 

[LizzyM]

You can think like a doctor by putting on a white coat.

Mind Games: Sometimes a White Coat Isn’t Just a White Coat
http://www.nytimes.com/2012/04/03/science/clothes-and-self-perception.html

I'm waiting for someone to use this data to argue that they should be permitted to wear a white coat to take the MCAT exam.

 

[Bacchus]

Oh, you mean we didn't get a fundoscopy and onion-shell inclusions on microscopy?

Turns out random charts isn't a good substitution for a physical exam.

What?

I was stating it was a rare disease and I've seen one infant over the past 10 months that has been screened for any metabolic disorder. They're routinely screened for by all 50 states at birth (although the diseases screened for vary.) To have adult-onset is rarer than the disorder we're all familiar with. A general population carrier rate for the trait is approximately ~1/250. No, it's not 1/10000 or 1/1000000 but I'd still consider it rare, even if you work exclusively with an Aschenazi Jewish population that has a heterozygote carrier rate of ~1/27.

To suggest I've not seen more because I don't look for the changes you've highlited on all physical exams is silly. There's a reason we use risk stratification and screenings... to save time and money.