MD & DO I can't make heads or tails of this question

[Peach Newport]

This is not a homework question.

My friend who is now an intern sent me this question. He said it was an "excellent" question to summarize what you "should have learned in your first year." I read the question and I think he might be trolling me. This is the kind of guy who would find it hilarious to send me on a wild goose chase, but he's also been helpful. I can't understand it at all, but maybe one of you can understand it?

A 35 year old male presents to a rural health clinic with complaints of persistent dry mouth, a palpable lump on his anus, erectile dysfunction, profuse diarrhea, and intermittent, painful upper-rectal spasms. He has also been urinating more frequently and drinking more frequently, but has a reduced appetite. His blood pressure is 120/80 and his pulse is 75. He reports that he recently stopped abusing methamphetamine, although the symptoms began one month after cessation. He denies using alcohol or other drugs, though smokes cigarettes. What condition do you immediately suspect, and why might it be causing dry mouth?

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[sloop]

Possibly a goose chase but, if not, the most likely answer is that this is a lying, potentially malingering patient and the patient has dry mouth because he's using meth.

 

[Peach Newport]

Possibly a goose chase but, if not, the most likely answer is that this is a lying, potentially malingering patient and the patient has dry mouth because he's using meth.

Why would a malingering patient report diarrhea, erectile dysfunction, rectal spasms? No real pain, and a whole bunch of symptoms that clearly won't score them drugs? What's he trying to score, a free DRE?

 

[tymont12]

Why would a malingering patient report diarrhea, erectile dysfunction, rectal spasms? No real pain, and a whole bunch of symptoms that clearly won't score them drugs? What's he trying to score, a free DRE?

...Whatever gets your rocks off.

 

[sloop]

Why would a malingering patient report diarrhea, erectile dysfunction, rectal spasms? and a whole bunch of symptoms that clearly won't score them drugs? What's he trying to score, a free DRE?

Assuming the question is a serious one:

I said potentially malingering, can't be sure based on the information. He's probably still using meth, just based on his symptoms. He has dry mouth, anorexia, erectile dysfunction. He might be drinking and urinating because of dry mouth. Diarrhea is a less common side effect of amphetamine but can happen. Or, he could be coabusing another drug like opiates and be withdrawing from that. The pain complaint could be to score pain meds.

Of course he may be having real symptoms. Just saying that a meth addict with some sympathomimetic symptoms and pain complaints is suspicious, especially when the question is prefaced with the possibly facetious "this is one thing you should have learned quickly in med school."

 

[Peach Newport]

...Whatever gets your rocks off.

My answer: The patient is making up symptoms in hopes of being digitally penetrated by a physician, and his mouth is dry because of the massive sympathetic stimulation caused by his anticipatory orgasm. Next case!

 

[Peach Newport]

Assuming the question is a serious one:

I said potentially malingering, can't be sure based on the information. He's probably still using meth, just based on his symptoms. He has dry mouth, anorexia, erectile dysfunction. He might be drinking and urinating because of dry mouth. Diarrhea is a less common side effect of amphetamine but can happen. Or, he could be coabusing another drug like opiates and be withdrawing from that. The pain complaint could be to score pain meds.

Of course he may be having real symptoms. Just saying that a meth addict with some sympathomimetic symptoms and pain complaints is suspicious, especially when the question is prefaced with the possibly facetious "this is one thing you should have learned quickly in med school."

Would you expect his BP and pulse to be elevated if he was still using?

 

[Soy un pelotudo]

I might be biased trying to have one unifying etiology but diabetes would at least explain the dry mouth, polyuria, and erectile dysfunction. Doesn't sound like the patient is in diabetic ketoacidosis but certainly diarrhea & reduced appetite fit the bill. I know maternal gestational diabetes can lead to congenital sacral defects in the offspring but not sure what to make of his "lump in his anus." (also considering other causes such as HPV, hemmorhoids, e.g. non-related to other symptoms) Rectal spasms may also be unrelated although a drug user may be inserting suppositories into his anus, ect, don't know if neurologic sequalae from diabetes could explain this.

 

[Stagg737]

Would you expect his BP and pulse to be elevated if he was still using?

Yes, but it can vary based on when his most recent fix was and his tolerance. Imo he's still abusing meth/abusing some other drug (maybe alcohol?). The lesson you're supposed to learn is that patient histories are often unreliable and you should take what some patients say with a grain of salt (especially the ones who have a history of drug abuse or other crappy behavior).

You should have been taught this in first year, but most med schools are more focused on teaching us how to play nice with our patients and that with enough caring and respect we can all be one big happy family. The reality is closer to Gregory House's core principle that "everybody lies".

 

[sloop]

Would you expect his BP and pulse to be elevated if he was still using?

Eh, probably. But it likely depends on the person, where they run at rest, how much they took, how, and when. I haven't seen much meth since it's not popular in this area of the country, but while uncommon I have seen a few people on cocaine with normal vitals. Granted, I also don't think these people were toxic from it.

DKA is a decent thought, especially if there was a history of diabetes.

Still, this is a very weird symptom constellation. Obviously I would try to rule out real physical illness, but generally my experience has been that when people come in with multiple complaints in various organ systems that don't seem to make sense, something fishy is going on.

 

[evilbooyaa]

He's likely got 'da sugahs', uncontrolled.

Explains quite a few things- poor appetite, frequency of urination with dry mouth, erectile dysfunction.

Then he may have hemorrhoids from having frequent diarrhea (due to diabetes?) and gets pain referred to the upper rectal area whenever he accidentally compresses one of his external hemorrhoids.

Or maybe there's a ton of things wrong with him, he has advanced anal cancer (causing rectal symptoms) due to HPV, exposed due to unsavory things he had to do to pay for his meth addiction, maybe HIV for added measure as an immunosuppressant.

How do you figure the difference between these two out?

Start with a history and physical. We all parrot that every single time, but it truly is important, especially in the undifferentiated patients.

That's probably the real takeaway from this - Not whether you for sure know the diagnosis, but you know HOW you're going to figure out what's wrong with him.

Or not. Only you know if your friend can be that deep or not.

 

[Stagg737]

Eh, probably. But it likely depends on the person, where they run at rest, how much they took, how, and when. I haven't seen much meth since it's not popular in this area of the country, but while uncommon I have seen a few people on cocaine with normal vitals. Granted, I also don't think these people were toxic from it.

DKA is a decent thought, especially if there was a history of diabetes.

Still, this is a very weird symptom constellation. Obviously I would try to rule out real physical illness, but generally my experience has been that when people come in with multiple complaints in various organ systems that don't seem to make sense, something fishy is going on.

I live near a place that was considered the meth capital of the world for a while and have seen quite a few users. A good number of them have pretty normal vitals but obvious outwards signs and symptoms of meth abuse (tremors, track marks, yellow teeth, etc).

I still say the lesson you "should have learned" is that patients aren't reliable historians and lie, but there's plenty of other things that could be going on. Imo the case isn't meant to have an obvious answer, it's meant to make you think and demonstrate whether you've learned the proper steps to work up a patient (H&P --> labs --> diagnostic testing, etc all the while keeping a running ddx in the back of your mind).

 

[sloop]

pain referred to the upper rectal area whenever he accidentally compresses one of his external hemorrhoids.

What? This is not how referred pain works. For one, referred pain occurs when the fibers innervating the peritoneum synapse at the same spinal level as a somatic dermatome. The organ pain gets referred to the dermatome, not the other way around. The anus inferior to the dentate line is innervated by somatic afferents whereas superiorly it is not. Pain from an external hemorrhoid is from somatic afferents to begin with and cannot be "referred" to a dermatomal distribution since it is already part of that distribution. It certainly can't be "referred" to the superior rectum.

 

[KHE]

Maybe something like Behcet's Disease?

 

[sloop]

Maybe something like Behcet's Disease?

 

[evilbooyaa]

What? This is not how referred pain works. For one, referred pain occurs when the fibers innervating the peritoneum synapse at the same spinal level as a somatic dermatome. The organ pain gets referred to the dermatome, not the other way around. The anus inferior to the dentate line is innervated by somatic afferents whereas superiorly it is not. Pain from an external hemorrhoid is from somatic afferents to begin with and cannot be "referred" to a dermatomal distribution since it is already part of that distribution. It certainly can't be "referred" to the superior rectum.

Feel free to quote me the textbook explanation of somatic pain (or anything else if you want), but you'll understand when you get out in the real world, people can have pain in weird areas, from weird things that wouldn't make sense if all you believed was what was in the books.

Let me put it this way - Do you think that it is more likely that the lump and the rectal spasms are related to each other, or that they're completely separate processes?

 

[sloop]

Feel free to quote me the textbook explanation of somatic pain (or anything else if you want), but you'll understand when you get out in the real world, people can have pain in weird areas, from weird things that wouldn't make sense if all you believed was what was in the books.

Let me put it this way - Do you think that it is more likely that the lump and the rectal spasms are related to each other, or that they're completely separate processes?

I think it's more likely that they're unrelated (or at least, that specific lump is not related to the superior rectal spasms). Why would it be? The explanation you gave was simply made up. You're pretending your hypothesis is a parsimonious explanation yet it involves ignoring science we know about how pain works . . .

Your explanation makes no sense and you should graciously admit this rather than make some excuse about "well, even though the textbooks disagree, medicine is messy so I'm probably still right anyway." Thinking this way is just lazy medical reasoning. That said, I don't think you're lazy. I think you're trying to save face.

 

[evilbooyaa]

I think it's more likely that they're unrelated (or at least, that specific lump is not related to the superior rectal spasms). Why would it be? The explanation you gave was simply made up. You're pretending your hypothesis is a parsimonious explanation yet it involves ignoring science we know about how pain works . . .

Your explanation makes no sense and you should graciously admit this rather than make some excuse about "well, even though the textbooks disagree, medicine is messy so I'm probably still right anyway." Thinking this way is just lazy medical reasoning. That said, I don't think you're lazy. I think you're trying to save face.

Lol. Wow.

Anyways, when you read 'upper rectal spasms' you're reading it like a physician has assessed the situation and has come to that conclusion. That's not the case here.
Don't take it at face value when (most) patients when they start using terms like 'upper rectal spasms'. I would say especially for those with recent and questionably current use of meth. Question is phrased as if patient comes in to you with these specific complaints, because the way it's worded, clearly an H&P (really the P) hasn't been performed yet. Patient is most likely unable to differentiate upper rectal spasms from lower rectal spasms or just intermittent general lower abdominal pain.

Do you use parsimonious colloquially or are you doing it to try to look smart on the internet?

But, you're probably right. Referred pain was probably the wrong term to use in this setting, since the somatic pathways wouldn't necessarily cause that. But rectal discomfort (with a feeling of intermittent'spasm' when the pain got bad) due to a hemorrhoid? I wouldn't immediately start chasing a differential cause from one vs the other.

Who knows, maybe he has a bag of meth shoved up there causing him discomfort, and he says 'upper rectal' cause he knows that he put it in exactly 10.5cm in from the anal verge.

 

[sloop]

Lol. Wow.

Anyways, when you read 'upper rectal spasms' you're reading it like a physician has assessed the situation and has come to that conclusion. That's not the case here.
Don't take it at face value when (most) patients when they start using terms like 'upper rectal spasms'. I would say especially for those with recent and questionably current use of meth. Question is phrased as if patient comes in to you with these specific complaints, because the way it's worded, clearly an H&P (really the P) hasn't been performed yet. Patient is most likely unable to differentiate upper rectal spasms from lower rectal spasms or just intermittent general lower abdominal pain.

Do you use parsimonious colloquially or are you doing it to try to look smart on the internet?

But, you're probably right. Referred pain was probably the wrong term to use in this setting, since the somatic pathways wouldn't necessarily cause that. But rectal discomfort (with a feeling of intermittent'spasm' when the pain got bad) due to a hemorrhoid? I wouldn't immediately start chasing a differential cause from one vs the other.

Who knows, maybe he has a bag of meth shoved up there causing him discomfort, and he says 'upper rectal' cause he knows that he put it in exactly 10.5cm in from the anal verge.

1. The whole thing is very vague. I tend to interpret "presents with" as the facts of the case, compared to "complains of" but whatever. This is a small point.
2. I have used the word parsimonious colloquially, but who cares? It is the perfect word for the concept I was trying to reference. Why do you mock me for thoughtful diction? This seems very insecure.
3. What percentage of adults do you think have external hemorrhoids? This is so common that the chances of having them concomitantly with an unrelated ailment are high. If you start chalking up to hemorrhoids pain that, if literally interpreted, should have no anatomic relationship to them, you are going to get into trouble.

 

[Peach Newport]

1. The whole thing is very vague. I tend to interpret "presents with" as the facts of the case, compared to "complains of" but whatever. This is a small point.
2. I have used the word parsimonious colloquially, but who cares? It is the perfect word for the concept I was trying to reference. Why do you mock me for thoughtful diction? This seems very insecure.
3. What percentage of adults do you think have external hemorrhoids? This is so common that the chances of having them concomitantly with an unrelated ailment are high. If you start chalking up to hemorrhoids pain that, if literally interpreted, should have no anatomic relationship to them, you are going to get into trouble.

I think the question is supposed to be implying "patient reports an intermittent pain in his upper rectum that feels like a muscle spasm," for what it's worth. I just read it as "rectal cramps." Like if a woman reported menstrual cramps. I might be totally wrong though.

 

[sloop]

I think the question is supposed to be implying "patient reports an intermittent pain in his upper rectum that feels like a muscle spasm," for what it's worth. I just read it as "rectal cramps." Like if a woman reported menstrual cramps. I might be totally wrong though.

Yeah fair enough. To be honest, the answer to this question is "who the **** knows, need more information."

 

[Psai]

He has some **** going on that's messing with his autonomic system

 

[hopefulERdoc251]

What? This is not how referred pain works. For one, referred pain occurs when the fibers innervating the peritoneum synapse at the same spinal level as a somatic dermatome. The organ pain gets referred to the dermatome, not the other way around. The anus inferior to the dentate line is innervated by somatic afferents whereas superiorly it is not. Pain from an external hemorrhoid is from somatic afferents to begin with and cannot be "referred" to a dermatomal distribution since it is already part of that distribution. It certainly can't be "referred" to the superior rectum.

So your science is right but I'm sure in practice it's hard to delineate what's inferior vs superior rectal pain specifically. You can have pain in your rectum and it still be via somatic pain radiating to the upper rectum (making it seem as though there is referred pain). It's like looking at a brachial plexus injury. Sure if you damage the median nerve, in theory you should get the first 2 and half fingers loss of sensory innervation, etc, but an ortho who came in to talk about it in class said that rarely do you get that exact distribution along the dermatome.

EDIT: I'm also only a first year so idk wtf i'm talking about

 

[sloop]

So your science is right but I'm sure in practice it's hard to delineate what's inferior vs superior rectal pain specifically. You can have generalized pain in your rectum and it still be via somatic pain through the pudendal nerve. It's like looking at a brachial plexus injury. Sure if you damage the median nerve, in theory you should get the first 2 and half fingers loss of sensory innervation, etc, but an ortho who came in to talk about it in class said that rarely do you get that exact distribution along the dermatome.

The issue here is that this is not exactly the same thing as people having somewhat variant dermatome distributions. The tissue below the dentate line is one kind of tissue with somatic afferents, above it is a different type without somatic afferents. There are no somatic afferent fibers in the superior rectum. Pain from the superior rectum that is generalized would be visceral pain. The pudendal nerve does not innervate above the dentate line. Innervation there is supplied by the inferior hypogastric plexus, not somatic nerves.

EDIT: I'm also only a first year so idk wtf i'm talking about

Haha. You probably know more about this than I do. I'm a fourth year going into psychiatry and haven't really studied anatomy in 3 years.