Your best diagnosis

[BobBarker]

Let's hear the best med student diagnoses. We do provide something to patient care on occasion other than playing the role of note monkey!

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[lilnoelle]

I diagnosed a guy that had been having panic attacks for a year, was continually presenting for chest pain and had multiple cardiac workups as well as seen several specialists who just couldn't find anything wrong with him. Each time he had an episode, his description would resemble an MI - yet when the tests were done, there was nothing. He was a young guy (~30) and otherwise healthy.
He came in to my FM preceptors clinic and I listened to his story - and it was remarkable how clearly these attacks were secondary to anxiety. It was nearly textbook.
Yet he had undergone multiple workups and no one else had diagnosed it as such. Made me wonder if any of the physicians involved had taken the time to listen to the guys story, or if it was just a matter of hearing "chest pain" and then doing a bunch of tests.

 

[Kedan]

Hmm I can't remember too many awesome diagnoses. I once diagnosed cellulitis on the medicine ward, got savaged on the round because everyone else thought it was a DVT, then two days later it turned out to be cellulitis. It wasn't that great a diagnosis because the history was very typical cellulitis but I remember it cause of all the **** I caught for it. I still don't get what all the attitude was about.

 

[Droopy Snoopy]

From my unique position of standing on a stool, lurched over our exlap like she was a Twister mat, I happened to notice the source of her bleed before anyone else. It's really the only positive thing I've done for a patient since starting medical school.

 

[SouthernSurgeon]

I diagnosed a guy that had been having panic attacks for a year, was continually presenting for chest pain and had multiple cardiac workups as well as seen several specialists who just couldn't find anything wrong with him. Each time he had an episode, his description would resemble an MI - yet when the tests were done, there was nothing. He was a young guy (~30) and otherwise healthy.
He came in to my FM preceptors clinic and I listened to his story - and it was remarkable how clearly these attacks were secondary to anxiety. It was nearly textbook.
Yet he had undergone multiple workups and no one else had diagnosed it as such. Made me wonder if any of the physicians involved had taken the time to listen to the guys story, or if it was just a matter of hearing "chest pain" and then doing a bunch of tests.

a) Everyone knows it's anxiety; it's just that no one wants to deal with it.
b) If you walk into a docs office or ED and say "chest pain", you get the big-time workup. Everyone is too scared of liability to blow it off.

 

[SouthernSurgeon]

Diagnosed meningitis in a pt that the ED said was having "migraines"

 

[lilnoelle]

a) Everyone knows it's anxiety; it's just that no one wants to deal with it.
b) If you walk into a docs office or ED and say "chest pain", you get the big-time workup. Everyone is too scared of liability to blow it off.

a)I got the impression people had thought of anxiety - as in they had probably dismissed his claim as psychosomatic after the initial event, but panic attacks and simple anxiety are distinct entities and panic attacks are very treatable.
b)Yes, I get why he got the workup. I don't get why he was worked up 20+ times and sent to several specialists.

 

[Richspiders07]

35 yr old smoker w/ sudden onset left shoulder weakness. No neuro deficits, no hx trauma, etc. Told my FM preceptor that we should get chest xray to look for an apical lung tumor... voila. Poor guy.

 

[Jamers]

Let's hear the best med student diagnoses. We do provide something to patient care on occasion other than playing the role of note monkey!

DeBakey type I aortic dissection. Took me around 2 hours to convince my attending to get a CT. Got to go home early for day because of that one.

 

[RxnMan]

I had several psych diagnoses when on FP. One dude broke down crying describing all of the tests he had gone through to diagnose his somatizations.

A classmate had the best I've heard of: Noticed the triad of HTN, hypo K, and hypernatremia in a pregnant pt. Told the OB resident at rounds the pt needed a workup and surgery consult. Resident laughed, and replaced K. Repeat x 3 days, until my classmate could get the attending alone. Consult ensued, resident shamed, student exonerated.

 

[It'sElectric]

58 yo male presenting to ED c/o syncopal episodes, confusion, and acting a little out of character (per family on the last one), with most recent syncopal episode resulting in a minor single car accident. Upon further questioning, the man has been having hematochezia for approximately a year. Stool guiac +.

To make a long story short, the long-term work-up confirmed my worst case scenario differential dx of colon ca with mets to brain. Obviously, not the first thing you think of when someone comes in with some AMS and syncope, but I couldn't help but put it high on my list. The guy was the type who pretty much ignored every sign/symptom his body was throwing his way, until his family insisted he be seen. Unfortunate, because it could've all been prevented with just a routine colonoscopy.

Other than that, I just write notes for a living, occasionally pretending to do something vitally important.

 

[BobBarker]

45 yo female presents to ER c/o "swollen veins", leg pain, and her chronic pancreatitis pain. Patient has known, stable, polycystic kidney disease. She has presented to this ER 3x in the past two months with complaints of "pancreatitis pain", treated, and released. Primary reason, she presents to ER is leg pain secondary the swollen veins and that she is fearful that they might "bust". Over the past 12 mos she has been worked up from mast to stern for GI disorder with no findings other than a high lipase and signs/symptoms of pancreatitis. She has been treated at a total of 4 different hospital ERs, and admitted occassionally for treatment of pancreatitis. Today, lipase is normal. Physical findings: mid-epigastric TTP, RUQ TTP, superficial thrombophlebitis R leg 2 locations. Pancreatic Cancer is very high on student's differential. Talks resident into ordering CA19-9. Days later 19-9 comes back >30K. Previous CT study indicated lesion on liver. Lesion on liver is biopsied consistent with pancreatic cancer.

 

[ZincFingers]

28 yo male presents to rural ER with recurrent fevers, cough, pleurisy, bilateral tingling numbness on fingers, swelling, arthralgias. On questioning, pt admitted to dark brown urine. Got the dx of polymyositis... ok, not that big of a deal I guess, but I did it without having any rheum labs available until a few days later... nurse didn't even know what "ANA" was.

 

[jbp100]

45 yo female presents to ER c/o "swollen veins", leg pain, and her chronic pancreatitis pain. Patient has known, stable, polycystic kidney disease. She has presented to this ER 3x in the past two months with complaints of "pancreatitis pain", treated, and released. Primary reason, she presents to ER is leg pain secondary the swollen veins and that she is fearful that they might "bust". Over the past 12 mos she has been worked up from mast to stern for GI disorder with no findings other than a high lipase and signs/symptoms of pancreatitis. She has been treated at a total of 4 different hospital ERs, and admitted occassionally for treatment of pancreatitis. Today, lipase is normal. Physical findings: mid-epigastric TTP, RUQ TTP, superficial thrombophlebitis R leg 2 locations. Pancreatic Cancer is very high on student's differential. Talks resident into ordering CA19-9. Days later 19-9 comes back >30K. Previous CT study indicated lesion on liver. Lesion on liver is biopsied consistent with pancreatic cancer.

Good pickup... I have wondered in the past why tumor markers are not used for screening more often. Like if you suspected colon cancer, you are not supposed to use CEA as a screening test, but if it were grossly elevated, would that not tell you something? Or in this case with the CA19-9.

Evidence based medicine, you are not my friend!

 

[bigDinLV]

a)I got the impression people had thought of anxiety - as in they had probably dismissed his claim as psychosomatic after the initial event, but panic attacks and simple anxiety are distinct entities and panic attacks are very treatable.
b)Yes, I get why he got the workup. I don't get why he was worked up 20+ times and sent to several specialists.

It's a rule out.. You know, make the list of things that it could possibly be. Eliminate the most serious things from the list..

Even when a known panic attack hits the ER and says they have chest pain, they always get the EKG etc. You're screwed if you don't...

 

[UCLAstudent]

26 yo F c/o subjective memory loss, progressive decline in knowledge, apathy, lethargy, and occasional bouts of panic about the future accompanied by restlessness and nausea. Dx w/ senioritis.

Oh, wait, that's me.

 

[OldPsychDoc]

It's a rule out.. You know, make the list of things that it could possibly be. Eliminate the most serious things from the list..

Even when a known panic attack hits the ER and says they have chest pain, they always get the EKG etc. You're screwed if you don't...

Yes, psych patients have heart attacks too, but I have to agree with lilnoelle--20 negative workups and NO ONE took the time to do psychoeducation about panic attacks?

lilnoelle--I hope you're thinking of coming over to join us on the Dark Side.

 

[caffeine37]

I had several psych diagnoses when on FP. One dude broke down crying describing all of the tests he had gone through to diagnose his somatizations.

A classmate had the best I've heard of: Noticed the triad of HTN, hypo K, and hypernatremia in a pregnant pt. Told the OB resident at rounds the pt needed a workup and surgery consult. Resident laughed, and replaced K. Repeat x 3 days, until my classmate could get the attending alone. Consult ensued, resident shamed, student exonerated.

what's that diagnosis?

 

[BobBarker]

Hyperaldosteronism, aka Conn's Syndrome. I had to look it up. Didn't recognize that triad..

 

[45408]

Hyperaldosteronism, aka Conn's Syndrome. I had to look it up. Didn't recognize that triad..

thanks, I was puzzling over it too

 

[jonb12997]

thanks, I was puzzling over it too

I was a little confused on that too...

my diagnosis....

80ish year old lady presents to the ER with pruritis x2 weeks and yellow skin (ok she was the color of a banana, I'll never forget that...) feel a belly mass, fatigued for a couple months, mother died of pancreatic cancer... "I don't want any tests or anything done"... convince her to do a CT scan of her belly. Pancreatic CA with liver mets, goes home on hospice next morning after correcting a low K overnight, I see her obituary in the newspaper about 3 weeks later...

 

[RxnMan]

what's that diagnosis?

Conn's. At least, that's how it shows up in your usual daily Chem 7's and vitals. The aldo level confirms it.

I think it was a good pick-up on the student's part, and a criminal reaction on the resident's. This was on the OB service, so when the attending told the resident to work it up and get the woman ready for surgery, the resident didn't know where to start. Thus, he put in a consult...for Medicine.

 

[RxnMan]

Yes, psych patients have heart attacks too, but I have to agree with lilnoelle--20 negative workups and NO ONE took the time to do psychoeducation about panic attacks?

lilnoelle--I hope you're thinking of coming over to join us on the Dark Side.

I had one woman who had the same story and I told her that she likely had an anxiety disorder. I educated her on what that meant, what treatments were available, and she seemed agreeable. It was a busy clinic day, so after I presented the case to my resident, he went in with her while I went to see pt #2.

I come out after pt #2 to see my anxiety lady screaming and yelling at my resident, making a scene, cursing, all while dragging her crying autistic child beind her.

My resident informed me that she exploded after he told her she wasn't going to get 90 Xanax with 5 refills. Some people don't want education, and they don't want help. They want drugs.

 

[QofQuimica]

Yes, psych patients have heart attacks too, but I have to agree with lilnoelle--20 negative workups and NO ONE took the time to do psychoeducation about panic attacks?

It works both ways. I had a tearful patient who came in to the outpatient clinic complaining of stress and anxiety, and who almost didn't even bother to mention the chest tightness radiating to the left arm with exertion until I asked about chest pain offhand during the ROS. My attending and I personally walked that patient over to the ED, over the patient's vehement protests. Sure enough, cardiac enzymes were elevated. Pt was hospitalized.

 

[EM2BE]

Pt in ED saying he vomited everything he was eating. I suggested tumor on the list of differential (and of course got an odd look but the attending paid attention), and sure enough, the CT showed a duodenal tumor. Sad day. Not one I want to repeat again - esp since the poor guy was supposed to get a GI workup a year prior and missed his appt and never set a new one.

 

[werd]

as a med student, had a patient who was sold to me by my resident as sure-thing lung CA with a big lung mass and enlarged liver. i suggested that he may have an aspiration PNA and big liver both from EtOH... somehow it turned out i was right.
as a resident, diagnosed someone with acute spinal cord compression who was admitted from the ED as a pneumonia.

 

[ymgc]

On my family med rotation, i had a lady with a pulsatile abdominal mass. My resident ordered and ultrasound and told me a week later she had a 6.0 cm AAA. My first and only major dx of 3rd year

 

[Hurricane95]

scleroderma in a teenage guy who had joint pains and ulcers on his elbows and fingertip pads....knew it when I saw it right away because I had a patient like that earlier in my medicine rotation.

TB in a guy who previously had been tested but ruled negative....suggested we retest acid fast after he persisted complaining of some occasional bloody sputum...came back +, but by then several people had already been in/out of his room and he was not in isolation...

I saw a lady on medicine rotation who had severe BL OA in her knees and was complaining of bad leg pain, so I examined her and found one leg bigger than the other and TTP. Told the resident I thought it was DVT, since she had been laying in bed for about 2 weeks for other issues and was not fond of ambulating. So they dopplered her, and sure enough, massive clot. Lungs were clear by angio at the time. This was early friday evening, and unfortunately I found out that later that night after I had gone home for my golden weekend she developed a saddle embolus and died early sat morning...

Finally I can actually say that I saved a life directly, which felt awesome knowing that I really helped. Had been sent by my resident on medicine wards to go admit a young lady in her early 20s in the ER who had been complaining of some SOB and lightheadedness, along with tingling in her feet. She had + asthma history and was presumed to be having an exacerbation. That's all I was told - sounded like a straightforward admission for a third year student early on in the school year...
Before I go see her I looked up all her records online and find one ER note from 2 years earlier mentioning she had myasthenia gravis...
so I go to the ER to see her and find her laying obtunded and minimally responsive, with what appeared to be BL bell's palsy. Take a look at her labs and see ABG with pCO2 of 55 from 30 minutes prior, most other things WNL. According to nurse at the time the patient was perfectly ok apparently. So I frantically page my resident like 5x in a row and no response. I tell the nurse and she was basically no help....saying she was going to check on her in a minute. no one was doing jack. Wait, she says. So after no response within two minutes, I went to the omnicell (i knew one of the nurse's code), got an ABG kit, and redrew an ABG myself on the patient - rushed it to the upstairs lab and had them run it on the spot - pCO2 was 140. I remembered the words of one of our directors of medicine - "rapidly rising pCO2 = impending respiratory failure." Told the nurse and THEN she panics, so I paged the anesthesiologist on ER call to bring the crash cart. Within a few minutes they're intubating the lady...so by the time my resident actually got there, the whole thing was done and she was on the vent being supported. Turns out she had MG induced respiratory failure....another 5 minutes and she probably would have died, right there, on the ER bed supposedly on close observation by the nurses for her asthma complication...

 

[SouthernSurgeon]

Finally I can actually say that I saved a life directly, which felt awesome knowing that I really helped. Had been sent by my resident on medicine wards to go admit a young lady in her early 20s in the ER who had been complaining of some SOB and lightheadedness, along with tingling in her feet. She had + asthma history and was presumed to be having an exacerbation. That's all I was told - sounded like a straightforward admission for a third year student early on in the school year...
Before I go see her I looked up all her records online and find one ER note from 2 years earlier mentioning she had myasthenia gravis...
so I go to the ER to see her and find her laying obtunded and minimally responsive, with what appeared to be BL bell's palsy. Take a look at her labs and see ABG with pCO2 of 55 from 30 minutes prior, most other things WNL. According to nurse at the time the patient was perfectly ok apparently. So I frantically page my resident like 5x in a row and no response. I tell the nurse and she was basically no help....saying she was going to check on her in a minute. no one was doing jack. Wait, she says. So after no response within two minutes, I went to the omnicell (i knew one of the nurse's code), got an ABG kit, and redrew an ABG myself on the patient - rushed it to the upstairs lab and had them run it on the spot - pCO2 was 140. I remembered the words of one of our directors of medicine - "rapidly rising pCO2 = impending respiratory failure." Told the nurse and THEN she panics, so I paged the anesthesiologist on ER call to bring the crash cart. Within a few minutes they're intubating the lady...so by the time my resident actually got there, the whole thing was done and she was on the vent being supported. Turns out she had MG induced respiratory failure....another 5 minutes and she probably would have died, right there, on the ER bed supposedly on close observation by the nurses for her asthma complication...

I dunno...if you really wanted honors, you should have gone ahead and intubated them yourself.

 

[Hurricane95]

Nah, she would have died. It was near the beginning of third year, I'll be damned if I knew how to intubate anyone back then. And no, I didn't get honors...bastards...

 

[Blondbondgirl]

I made a house call with a rural FP for a 70 year old man who had just been discharged after pneumonia- he had a laundry list of dz in his PMH and before we entered his home the doctor told me he was a complainer and he assumed he was fine.
He complained of left foot pain and his left toes were a bit red but the doctor felt his foot- told me it was cold and started telling the patient to take a tylenol when I asked if it was a PAD (peripheral arterial dz) patient, which he was, and I took a deep breath and said I would admit him to rule out erysipelas (not knowing if I'd get yelled at, but it's not like I could wait till we were in the car again and we would go back in later- either way it put the other doc in a wierd situation in front of the patient's family).
Well, he agreed and later told me the patient was kept on iv antibiotics for several weeks and is now discharged again, doing much better!
I know it's not a huge diagnosis, but I felt pretty special!

 

[nlax30]

Nah, she would have died. It was near the beginning of third year, I'll be damned if I knew how to intubate anyone back then. And no, I didn't get honors...bastards...

Wow, tough crowd. Good catch though. Where was the ED doc through all of this?


I'm just 2 days into my first rotation (IM) and so far it's an eye opener. At this point our interns have us do the initial H&P for admits, morning progress notes, and present at rounds so I'm definitely getting practice with various types of write ups.

It felt nice today to catch bilateral carotid bruits in a pt during the physical. I presented that finding somewhat sheepishly as I knew my intern had also seen her and was waiting to be corrected about the carotids being totally clear, but apparently I nailed it. Feels good to get something right!

 

[SouthernSurgeon]

Wow, tough crowd. Good catch though. Where was the ED doc through all of this?

Yeah, I was wondering that. I think I would have just found the nearest ED resident or attending.

 

[subtle1epiphany]

I go to a free clinic at my hospital's satellite facility when I have time on rotations.

Pt had been having pain in her lower lumbar area and another pain anterior. She described them differently, the posterior was aching and dull (neg CVA tenderness, etc), the anterior sharp and burning.
After talking with her at length and hearing her concerns (which were many), I was begrudgingly chalking it up to pulled muscles due to the large amount of exercising she does.
She mentioned several times about an open appy prior to the anterior pain starting, which I pulled up in our system. Open as it was more complicated and converted from a lap.
For some reason I had an idea and asked her to re-describe her pain, the sharp pain wasn't fitting.

Iliohypogastric Neuralgia 2/2 procedure.
I couldn't believe it. It fit perfectly.
Gave her Elavil to start (had considered gabapentin) in addition to NSAID, reassured her and explained it as a potential complication, and gave her a follow-up as she requested. Not sure what we'll do next.

...and for next...did a nerve block of the iliohypogastric nerve (~1cm medial to the ASIS, subcutaneous), which completely removed her pain...so long as the lidocaine lasts. Increased her Elavil, added gabapentin.

 

[indo]

hypertension, uti, rash nos, swine flu x 30, rhinovirus....a real doozy...

 

[DD214_DOC]

Serotonin syndrome.

I did go in to see a woman for hip pain. 30 minutes later she was being admitted to the psych ward for being suicidal.

Otherwise nothing special. Usual COPD exac, CHF exac, yadda yadda

 

[Rendar5]

During my medicine sub-I we had an AMS woman in her 50s-60s come in who was normal mental status the next morning. She tested positive for benzo's on the drug screen. She had multiple meds that she was taking and we had a hard time sorting out the ones she was currently taking and which ones she wasn't. None of them were benzo's. No one in her family was taking benzo's. She had some symptoms of early dementia. But the AMS was being attributed to benzo's which the assumption was she was sneaking in on the side (despite no prior toxic habits of any sort). I found that one of her meds, oxaprozin (an NSAID) cross-reacted with the drug screen and produced a false positive. With that, after talking with her family doc, we correctly attributed the AMS and prior episodes to early onset dementia.

 

[IHeartNerds]

neuroblastoma by visual diagnosis due to opsoclonus-myoclonus. granted, anyone with half a brain could have figured it out, but i was the first one to see the kid. it was still pretty satisfying to have the rest of the $10,000 workup come back exactly the same as a three second glance.

 

[sweatybrain]

My favorite, and a patient whom I will always remember.

60 something hispanic man with h/o ESRD, alcoholism, and UGI bleed came in with fever and RUQ abdominal pain. About a month PTA, he was hospitalized for UGI bleed requiring transfusion. EGD done at the time showed a gastric ulcer, which was subsequently shown on biopsy to be poorly differentiated gastric CA (unbeknownst to us at the time of admission).

Anyway, we admitted him and did the 1 million dollars work up. RUQ US, HIDA, CT, MRI, indium scan were ALL negative or non-contributory, yet his bili and alk-P kept climbing: from 2 to 5 to 15 to over 30. Strangely enough, he also kept spiking a fever even while on vanco and zosyn. We were all puzzled by what was the underlying etiology.

Long story short, on a lucky day, we looked at blood smears as part of a tutor group and saw the pathognomonic Maltese cross. Diagnosis: Babesiosis. (Apparently, he got it from the transfusion.)

I don't think I will ever top that again, though my good friend diagnosed Hemophagocytic lymphohistiocytosis (HLH) at Memorial. It ended up being a NYT story and he is now doing residency in medicine at Cleveland Clinic.

I will miss medicine.

 

[FutureInternist]

I found that one of her meds, oxaprozin (an NSAID) cross-reacted with the drug screen and produced a false positive. With that, after talking with her family doc, we correctly attributed the AMS and prior episodes to early onset dementia.

Way to go the extra mile.

 

[plainolerichie]

I did not really make the primary diagnosis, but did show a complication. My resident sent to evaluate a guy who had "constipation" over months that was worsening, until he could not pass stool at all and was vomiting. He did not have any surgery, did not have a hernia. Stool got smaller and smaller, basically classic presentation of colon cancer. But my resident knew that so didn't make that diagnosis.

BUT the thing is, I was asking about complications. I asked he had any urinary symptoms, which he did, including increased frequency and passing "stones" over the last months. He had leukocites and nitrite positive urine. I suggested he may have a fistula and he did on CT scan! Nothing to spectacular and someone else may have found that too, but whatever!

Most of my "diagnoses" are figuring out where the EGD suite is in the new hospital, or the diagnosis of where to drop off PICC requests...