Differential Diagnosis

[CA0708]

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At 0630hrs, Wednesday, Gregory was found conscious in his bed bleeding from his rectum. He is 6 years old and has no prior history of illness or major surgeries. Arriving at the hospital, the paramedic noted that Gregory was pinching his abdomen as if he were in pain. The EM asked Gregory to rate his pain level on a scale of 1 to 10, 10 being the worst. Gregory was unable to speak. He began to choke and appeared to have gone into anaphlyatic shock. One day prior, Gregory returned from a field trip where he visited a local aquarium. The trip was designed to introduce the students to different species of arthropods.

You have 48hrs to find out what's wrong with him or his condition will continue to deteriorate without proper treatment.

 

[LADoc00]

okay, can we can get a holiday banning here?

 

[DrZPath]

This is the pathology forum, and most of us are either pathologists or in training to become pathologists. I feel obliged to inform you that one of the benefits of being a pathologist is that I'm actually not responsible for your patient at this point. I certainly wish him well and want to help you treat him as much as possible, but there is no actionable material for me yet. There is insufficient history, physical exam, and imaging data; it's not my responsibility to obtain any of these. However, if you consult me about lab testing on blood or stool specimens, or, even better, send me an adequate biopsy from a site which correlates with a grossly abnormal clinical appearance, I'm your man. Until then, you have work to do.

 

[CA0708]

Well, the point was to see if pathologists were proactive investigators. I know you guys wait to get your data then try to figure it out...but do you encounter cases where you do not have all the facts? I assumed that you would take samples from Gregory and go from there...

 

[Gut Shot]

I assumed that you would take samples from Gregory and go from there...

Yeah, we're going to need to breadloaf every major organ for sampling. I hope he's not too concerned about the cosmetic outcome.

 

[CA0708]

I...........cant........stop.........laughing..........so..........hard

 

[DrZPath]

Well, the point was to see if pathologists were proactive investigators. I know you guys wait to get your data then try to figure it out...but do you encounter cases where you do not have all the facts? I assumed that you would take samples from Gregory and go from there...

WTF? Go play your game somewhere else. Maybe they will find you and your ******* scenario less tiresome in the internal medicine forum, but I doubt it. At the least, get a f*cking clue.

 

[CA0708]

You know Dr. Scrooge, some first-time interns assume my case studies are just games. When they realize who I am and what position I have, they quickly realize in a real-world situation, nothing is what it seems, like how some diseases share the same signs and symptoms. I tell the younger ones to always keep an open-mind, stay on your toes, and think outside the box every once in a while, because one day that ego will cloud your judgement.

You should do the same in your career. You don't have to take my advice being that you are the subject matter expert in the field. But if you take anything from me, take this statement to heart: A narrow-minded, hot-head like you wouldn't cut it in my program. Have you got your clue yet?

WTF? Go play your game somewhere else. Maybe they will find you and your ******* scenario less tiresome in the internal medicine forum, but I doubt it. At the least, get a f*cking clue.

 

[DrZPath]

You know Dr. Scrooge, some first-time interns assume my case studies are just games. When they realize who I am and what position I have, they quickly realize in a real-world situation, nothing is what it seems, like how some diseases share the same signs and symptoms. I tell the younger ones to always keep an open-mind, stay on your toes, and think outside the box every once in a while, because one day that ego will cloud your judgement.

You should do the same in your career. You don't have to take my advice being that you are the subject matter expert in the field. But if you take anything from me, take this statement to heart: A narrow-minded, hot-head like you wouldn't cut it in my program. Have you got your clue yet?

My clue is that you're a *****. Your "case study" is exactly what you suggest, a game, when you post it in such a way and expect that other readers of this forum will play it. Your game might be appropriate for 1st-year medical students and pre-meds, but not for the senior students, housestaff, and pathologists that are more likely to frequent this place. Pathology is a consulting specialty; in the real world, you don't call a consultant with minimum information and tell them they have 48 hours to "crack the case" -- not unless your goal is to have them laugh at you. If you want results, provide the right material to the right consultant. And my mind is quite open; I can learn something from anyone, although you're shaping up to be an exception.

 

[mcfaddens]

You know Dr. Scrooge, some first-time interns assume my case studies are just games. When they realize who I am and what position I have, they quickly realize in a real-world situation, nothing is what it seems, like how some diseases share the same signs and symptoms. I tell the younger ones to always keep an open-mind, stay on your toes, and think outside the box every once in a while, because one day that ego will cloud your judgement.

You should do the same in your career. You don't have to take my advice being that you are the subject matter expert in the field. But if you take anything from me, take this statement to heart: A narrow-minded, hot-head like you wouldn't cut it in my program. Have you got your clue yet?

Where is Yaah? Or someone to get rid of this guy, hes a waste of space and time, has no clue what he is talking about and is really dumbing down our forum. Listen pal go back to screwing around in your pre med forum.

 

[TheCritic]

I...........cant........stop.........laughing..........so..........hard

Now I understand your genius. You're testing the knowledge base of pathologists by posting a half baked scenario on an internet forum to see who responds. Dude get a f-ing life.

Oh incidentally:

http://www.343guiltysnark.com/wp-content/uploads/2006/09/douchebag2.jpg

 

[deschutes]

We've had sillier threads in the past - I don't think we're at the level of disruption where the thread needs to be closed and the OP banned. Ignoring would probably work fine for now.

By the way there is an option under "My Account" (formerly "user CP") on the left of the top blue bar of the page to "ignore" certain users if you type in their username. Few know about this and I actually don't use it myself but you can try it if you want.

 

[CA0708]

My clue is that you're a *****. Your "case study" is exactly what you suggest, a game, when you post it in such a way and expect that other readers of this forum will play it. Your game might be appropriate for 1st-year medical students and pre-meds, but not for the senior students, housestaff, and pathologists that are more likely to frequent this place. Pathology is a consulting specialty; in the real world, you don't call a consultant with minimum information and tell them they have 48 hours to "crack the case" -- not unless your goal is to have them laugh at you. If you want results, provide the right material to the right consultant. And my mind is quite open; I can learn something from anyone, although you're shaping up to be an exception.

You are just lazy. Pathology is not a consulting specialty. It is an investigative specialty.

 

[CA0708]

Now I understand your genius. You're testing the knowledge base of pathologists by posting a half baked scenario on an internet forum to see who responds. Dude get a f-ing life.

Edit:

There's nothing wrong with using your head from time to time. You work in a lab most of your career, unfortunately I'm too extroverted for the task; but I think radiologists are the true moles of my hospital. At any rate, I have nothing against you or your profession. Some of you civilians take life far too seriously sometimes - you get upset over so many frivolous things - get over yourself so you don't end up being "that guy."

 

[CA0708]

Where is Yaah? Or someone to get rid of this guy, hes a waste of space and time, has no clue what he is talking about and is really dumbing down our forum. Listen pal go back to screwing around in your pre med forum.

I take it you've noticed I tend to post everywhere. Hell, half the time it's for no real good reason; then again, it doesn't take a rocket scientist to answer common sense questions. Welcome to the World Wide Web kid - unless you're older than me.

It's a surreal feeling to still see kids in positions or predicaments that I used to be in at their age. It's even more hilarious to see folks are as arrogant, stubborn, and hot-headed as I used to be. I'm probably a little arrogant and stubborn, but I think I finally matured enough to move pass the hot-headed trait.

 

[b&ierstiefel]

Yeah, we're going to need to breadloaf every major organ for sampling. I hope he's not too concerned about the cosmetic outcome.

Dude, that's hilarious!

I don't think we're at the level of disruption where the thread needs to be closed and the OP banned.

Yeah, I agree...I've seen far worse things that don't result in bannings. But I stopped giving a damn about it a long time ago. Plus, this guy doesn't rile up a whole lot of hostile feelings within me anyway. I am curious as to where this thread goes though...it has the potential to get really entertaining.

WTF? Go play your game somewhere else. Maybe they will find you and your ******* scenario less tiresome in the internal medicine forum, but I doubt it. At the least, get a f*cking clue.

Yeah, not really inclined to play this game while I'm on vacation...or when I return to work in a few days.

 

[b&ierstiefel]

OK...let's do this.

Enough of Gregory. Gregory's mom on the other hand has a peritoneal nodule. On histology, it looks like this:

On higher power...

Thoughts? (If you've seen this before, it's pretty easy...I consider it an Aunt Minnie type of a diagnosis...if you haven't, well you've learned something 🙂 )

Cheers.

 

[CA0708]

I have a feeling some people here aren't even in medical school or a handful of pathologists (here) have a thing against MDs in general. I noticed this trend in practice where I train. I noticed we have a "bandwagon effort" going on here too; and I have a list of common responses to that statement already on paper. I'm sure this will bring a flame against me (The Red Scare).

One Encounter with a Pathologist​

I had a case come in and no one knew what to make of it. The patient had no medical records or insurance, but arrived via an EMS crew, unconscious, but stable. The call came from a driver who notice the man was lying face down not moving on a sidewalk. We went into the lounge. We figured our best guess was to test for drugs. Tested negative. When we went to the Internist for advice, she said, "well did you test for drugs?" We did a fMRI scan to see if it may have been a stroke (unlikely because of his age); and to determine if his head injury explains why he was unconscious on the sidewalk in the first place; or if there was a tumor (brain edema for $400?). The neurologist came back and said it's unlikely that he had a stroke; a turmor; but the only signs of trauma were superficial (and the force of the impact (the fall) wasn't severe enough to cause sTBI or damage to the frontal bone; and his brain patterns were within normal functioning parameters. The sTBI would have been our easy-out, but it didn't explain why the patient was still unconscious - according to the neurologist.

We went to a pathologist, because we needed to find out why this man was still unconscious. He did not seem happy...."What the hell do you want me to do? What do you mean we don't have anything on this guy? Try Internal, this isn't a pathology job." Must have had a busy week...

We ran a second blood test without the pathologist and found the problem. Not all patho-guys in the hospital are like this (eager to throw away cases they don't want, but will kiss your ass when you land on the jackpot); AGAIN, most pathologist I've met are very professional.

P.S. The patient had a rare, but potentially lethal pathology.

 

[CA0708]

I can see a team of pathologists chasing me with torches as we speak. Gone running...

 

[b&ierstiefel]

OK so this is a mass in a lady's uterus. Typical pelvic pain history so the GYN surgeon performs the hysterectomy and the bulky uterus specimen lands on our bench. Multiple nodular masses are present...histology on one of them shows this...

The bulk of the mass (one part of the mass)...

The interface between the above and the other part of the mass...

 

[DrZPath]

OK...let's do this.

Enough of Gregory. Gregory's mom on the other hand has a peritoneal nodule. On histology, it looks like this:



On higher power...



Thoughts? (If you've seen this before, it's pretty easy...I consider it an Aunt Minnie type of a diagnosis...if you haven't, well you've learned something 🙂 )

Cheers.

Cool, looks similar to a case of peritoneal keratin granulomas that I saw once. Did the patient have a concurrent ovarian tumor or history of one?

 

[b&ierstiefel]

Cool, looks similar to a case of peritoneal keratin granulomas that I saw once. Did the patient have a concurrent ovarian tumor or history of one?

You betcha...this patient has a grade 1 endometrioid with squamous differentiation within the uterus.

The first time I saw this entity was actually in the frozen section room and my first response was "WTF?" Of course, once you've seen one, you've seen em all...

 

[sohsie]

I can see a team of pathologists chasing me with torches as we speak. Gone running...

You are the same idiot who started this other asinine thread:

I have experience in biological sciences.
Pathology is an interesting field.
I enjoy reading and studying pathology.
I have experience in pre-hospital care.
EMS is an interesting field.
I enjoy working and studying pre-hospital care.
I enjoy fast-paced, high-risk, demanding working enviroments.
For me, an ideal working-enviroment is at a trauma center. Last time I checked, pathology wasn't a f**king requirement on the job! Unfortunately, I cannot see how a MS or PhD in Pathology is going to be put to use if I work in a trauma center. I plan on adding pathology as part of my education after graduation. Woe is me. I can't resist the call of infectious diseases.

What do you think about that? Maybe I should ask those psycho-MD/PhD/Multiple-Psychotic-Combined-15-year-Degree chums...

The psychiatry forum is four folders down from us. Thats where you need to go. Don't mind the funny backwards jacket they are fitting for you. Thats for your own good.

 

[DrZPath]

OK so this is a mass in a lady's uterus. Typical pelvic pain history so the GYN surgeon performs the hysterectomy and the bulky uterus specimen lands on our bench. Multiple nodular masses are present...histology on one of them shows this...

The bulk of the mass (one part of the mass)...

The interface between the above and the other part of the mass...

The sclerosis, papillary structures, and hobnail cells smack of clear cell carcinoma. It doesn't look so infiltrative in the second image, though. I would be interested to learn how this was signed out.

 

[CA0708]

You are the same idiot who started this other asinine thread:

The psychiatry forum is four folders down from us. Thats where you need to go. Don't mind the funny backwards jacket they are fitting for you. Thats for your own good.

I'm glad you are able to do research. I didn't think you had it in you to track me down. What's your point?

 

[CA0708]

What made my stomach churn during my intern year was the site of a motorcyclist with an open fracture to his right femur. A week or so later, it became infected.

 

[b&ierstiefel]

The sclerosis, papillary structures, and hobnail cells smack of clear cell carcinoma. It doesn't look so infiltrative in the second image, though. I would be interested to learn how this was signed out.

Good that you mention clear cell cuz it is on the differential. BTW, it's funny how clear cell carcinoma seems to pop up more frequently than expected on differential diagnoses.

You're right, it wasn't infiltrative. Grossly this was a well circumscribed nodule that would've been brushed off as a leiomyoma. How about this? Immunostains were done for fun on this case...mesothelial markers were positive.

e.g., here's a calretinin stain:

 

[DarksideAllstar]

I have a feeling some people here aren't even in medical school or a handful of pathologists (here) have a thing against MDs in general.

Actually, if you look at the people posting here, most of us are in or have been in medical school and are now residents. For added clarification, Pathologists ARE MD's. But you do have a point, I do have a thing against MDs who think they are "holier than thou" and seem to "know" everything. I hate those bastards.

Added tip: maybe you should relegate yourself to posting in the pre-allo forum til you post something that peripherally relates to pathology (like when the autopsy report comes back on your "case") and you actually have an idea of what our scope of practice entails.

 

[TheCritic]

What made my stomach churn during my intern year was the site of a motorcyclist with an open fracture to his right femur. A week or so later, it became infected.

Don't you mean, last Wednesday, when you were doing your pre-med volunteer work in the ER. Or the other day when you were watching Trauma life in the ER.

 

[b&ierstiefel]

But you do have a point, I do have a thing against MDs who think they are "holier than thou" and seem to "know" everything. I hate those bastards.

Don't forget those MDs who try to tell us how we should be doing our jobs. I say that in general...no relevance to the OP since he has no doctoral degrees.

 

[Circumflex]

We went to a pathologist, because we needed to find out why this man was still unconscious.

This is great - what did you expect a pathologist to do? Give me some tissue and I'll be glad to help in any way I can.

 

[yaah]

I can see a team of pathologists chasing me with torches as we speak. Gone running...

OK buddy, I'll bite (briefly). Am posting this publicly for the benefit of those who are thinking of similar action or want to respond to your obvious baiting.

I suspect you have no idea what a pathologist really does. I have my doubts that you even know what an MD is. But if you do, please don't bother to correct me, because it really doesn't matter. I suggest looking on any number of websites (like in our FAQ) to get some real information. Your posts smack of a combination of self absorption and cluelessness, in which point arguing with you is not only pointless but self-fulfilling for you. So until you start making sense with any of your posts or start clarifying why you are asking these bizarre questions, I don't think anyone is going to participate.

As best as I can tell, your purpose in coming on to this forum is to antagonize pathologists and cause confusion. This is not welcome. If you are serious about pathology and want to ask questions, feel free. If you have something against pathologists or pathology in general, even after learning more about what we actually do, then go ahead and complain instead of beating around the bush about it. If you're just trying to push peoples' buttons, then go away. If you're simply clueless, there is little point for you to post here.

If you want to post an interesting case from a pathology perspective, then fine, do it (like bierstiefel did). Basically what you are doing is posting about a case from an EMS perspective and then suddenly asking for pathology input. This makes no sense. Do you want someone to look at a blood smear? Interpret some strange abnormal results from automated lab tests? Read a biopsy? Again, please refer to the FAQ if you don't know what a pathologist does.

 

[yaah]

p.s. Bierstiefel my first thought on case #2 was adenomatoid tumor but it looks somewhat atypical (cytologically, primarily). Is there anything outside the uterus to make this part of a manifestation of mesothelioma?

 

[b&ierstiefel]

If you want to post an interesting case from a pathology perspective, then fine, do it (like bierstiefel did). Basically what you are doing is posting about a case from an EMS perspective and then suddenly asking for pathology input.

I don't think that's this guy's intention at all. I can smell his **** from a mile away and basically some of the hostile responses on this forum from others really serves to play into this guy's hands. I agree with you; there really is no reason to waste ATP molecules in responding to this guy's posts in any sense. He's laying a trap so that we can say stupid crap to give him ammunition to dish out crap against our profession. Look, I'll be the first one to admit that I went into pathology because I didn't have to deal with the crap that comes into the ER, didn't wanna deal with kids like "Gregory", and I wanted a nice predictable workday that comes with being a consultant...if that makes me lazy, fine so be it...but I don't think this should taint our profession. We're not crusaders. Anyways, his posts do expose him as someone who is naive and misinformed in some respects but compared to the typical premed who has no concrete experience in medicine, he's not that *****ic (I've seen a lot worse).

I have no qualms derailing this thread with real cases that could actually serve useful to us pathologists. I have gigs of images saved up from the past half a year and I'm happy to post more cases as needed...hell we can turn this thread into Holiday Path rounds.

To answer your question, it is an adenomatoid tumor. No extrauterine manifestations at the time of presentation. It's relatively a fresh case, so who knows what will happen to this patient in the future. Your point about cytologic atypia is well taken. However, adenomatoid tumors can have some scary cytology as I've learned. Furthermore, on the flip side, mesotheliomas (of both the pleural and peritoneal varieties) can be surprisingly cytologically bland too...hence the whole issue these days on whether mesotheliomas can or cannot be positively diagnosed on pleural fluid/peritoneal fluid cytology.

 

[b&ierstiefel]

27 year old with a 15 cm ovarian mass. Sorry, don't have a gross photo (the gross for the entity did come up on the RISE exam last year though) but here are some histo shots. No tricks here (if you felt there were tricks in the last 2 cases posted in this thread, my apologies)...but it's something we see in the textbook but not often in practice:

Reminiscent of something you might see in a testis???

 

[Docxter]

We did a fMRI scan to see if it may have been a stroke (unlikely because of his age);

You did what!!!?!!!? You know, just throwing in a couple a medical terms you've heard here and there just to pretend you're a doctor doesn't actually make you one. And don't think people are as stupid as yourself. fMRI good one.

 

[DarksideAllstar]

27 year old with a 15 cm ovarian mass. Sorry, don't have a gross photo (the gross for the entity did come up on the RISE exam last year though) but here are some histo shots. No tricks here (if you felt there were tricks in the last 2 cases posted in this thread, my apologies)...but it's something we see in the textbook but not often in practice:

Reminiscent of something you might see in a testis???

My guess is dysgerminoma. Nests of malignant cells with clear cytoplasm, fibrous septa, mononuclear inflammatory cell infiltrate. Adequate sampling to make sure its not mixed w/chorio, yolk sac, or embryonal.

 

[b&ierstiefel]

You guess correctly.

 

[LAZYGUY]

At 0630hrs, Wednesday, Gregory was found conscious in his bed bleeding from his rectum. He is 6 years old and has no prior history of illness or major surgeries. Arriving at the hospital, the paramedic noted that Gregory was pinching his abdomen as if he were in pain. The EM asked Gregory to rate his pain level on a scale of 1 to 10, 10 being the worst. Gregory was unable to speak. He began to choke and appeared to have gone into anaphlyatic shock. One day prior, Gregory returned from a field trip where he visited a local aquarium. The trip was designed to introduce the students to different species of arthropods.

You have 48hrs to find out what's wrong with him or his condition will continue to deteriorate without proper treatment.

Ddx can be wide for hematochezia.



Kid with hematochezia:
Meckel’s div
Amebic/bacillary dysentery
Allergen
Intussusception
Mesenteric artery thrombosis
Rectal polyp
Rectal prolapse
Hemorrhoids

Since you are a pre-med as suggested by your post and not realizing that most of the people above are physicians (MD/DO) you will find that in real medicine (unlike tv) the first thing you do is stabilize the patient. ABCs- intubation if airway is compromised, fluids/transfusions, to get him out of shock secondary to volume-depleted shock and possibly anaphylactic shock if an unknown allergen is in play (in which case use DA and epi, pred). Then only after the patient is stabilized do you even begin to look for pathology. If so your options then are to search for the bleeding OR (acute abdomen) vs RBC tagged study or colonoscopy/EGD to find and stop the bleeding.

Only, only after all that has been done do you start investigating and in some cases you may never truly know the answer, in most cases the workup above along with your lab panels will be fairly straight forward.

After all this has been worked up by internal medicine, you can consider consulting pathology. They are not going to do your workup for you.😉