Think Like a Doctor: A New Real Medical Case Study

Shelly Verma · Jan 2, 2014

Intestinal angioedema

Abriel · Jan 2, 2014

Bowel perforation or Crohn's disease

nikhil2408 · Jan 2, 2014

Egyptian Doctor said: ↑

The Challenge: Can you solve a medical mystery involving a previously healthy 47-year-old woman who for the past two years has had episodes of abdominal pain, nausea and vomiting so severe she has needed to be hospitalized?

We will provide some of the notes and imaging tests ordered by doctors who saw this patient. The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped many of the doctors at one of the great hospitals of the world.

The Patient’s Story

“Do you want me to pull over?” the middle-aged man asked anxiously as he glanced over at his wife. She had placed a plastic bag tightly against her mouth as her shoulders and upper body contracted in silent paroxysms of vomiting.

She shook her head once the spasms subsided, and he returned his full attention to the twilit highway before him. He knew that the most important thing he could do for his wife was to get her to the hospital as quickly as possible.

She had been fine that morning, working with their three children, whom she had been home-schooling. Then, late that afternoon, she began vomiting, over and over again, long after she had eliminated everything she had in her system. She and her children had eaten chicken salad for lunch, but everyone else felt fine.

And at this point it was a sadly familiar event. She had had several episodes like this over the past two years and had already spent weeks in various hospitals as doctor after doctor tried to understand where these paroxysms of terrible pain and incessant vomiting came from and how to make them stop.

Another Hospital Visit

Dr. Poonam Merai, the resident on call that day at the University of Chicago Medical Center, sighed when she got the text from the emergency room alerting her about a 47-year-old woman with abdominal pain and uncontrolled vomiting. It was only 10 in the morning, and they had already had quite a few patient admissions. It was going to be a busy day.

She flipped through the woman’s thin chart, then turned to her intern, Dr. Nathan Schoettler. “We might as well go see her; there’s not much in here,” she said as she returned the clipboard to its slot.

You can review the E.R. resident’s note here.

The patient’s room was dark when the two doctors-in-training arrived. Dr. Merai knocked on the open door and quickly introduced herself and the intern. “May I turn on the light?” she asked.

The patient rolled over to face the two young doctors and gave them a smile. Sure, she told them, why not? She told them about the events of the day before. She and her husband had arrived at the hospital in late afternoon and had been talking and getting tested until the wee hours of the morning. What more did they need to know?

The Patient’s History

It started nearly two years earlier, the woman told Dr. Merai. She had been at work — she was a clerk in a bank then — and had suddenly started vomiting. As she made her way back to her desk, she felt weak and unsteady and fainted. Or that’s what everybody told her, because the next thing she knew, she was in an ambulance on the way to the hospital.

There, a CT scan showed that her small intestines were inflamed. The doctors said she might have Crohn’s disease. But after a couple of days, she started to feel better and went home. Because she felt O.K., she never followed up.

And then, it happened again — nine months later. Again she was rushed to the hospital. Again a CT scan showed an abnormality in the small intestines. This time the doctors were so worried they took her straight into the operating room.

“They thought my guts were tangled up in knots,” she told the doctor. But when she woke up, the surgeon told her that he was amazed to see that her insides were pristine. There was swelling and a lot of fluid in her belly, but no twisting, and no infection. And nothing to take out.

At that hospital she had an endoscopy so doctors could look at her stomach and upper G.I. tract and a colonoscopy to look at the other end. Those exams were normal. They considered transferring her to the University of Chicago, the main medical center in the area, but after a few days on antibiotics, she got better and went home.

Six months later it happened again. She went to a third hospital and had another endoscopy, and another colonoscopy. Again, some small bowel inflammation was seen, and again there was talk of sending her to the University of Chicago. But again, she got better with I.V. fluids and antibiotics, and so she was sent home.

This last time, when the pain and vomiting started, she and her husband were determined to go straight to the University of Chicago. And so, here she was.

A Patient Who Looks Basically Well

Other than these crazy episodes of pain and vomiting, she felt quite well. She was careful with her diet and exercised regularly. And she was pretty good about taking the medications she was prescribed for her diabetes and high blood pressure. She didn’t smoke or drink, and when she wasn’t working with her children, she worked with the students at a local elementary school in their after-school program.

On exam, the doctor noted that the patient was a friendly and well-appearing African-American woman. Her pain had been intolerable when she first arrived — an 8 or 9 on a scale that went from 1 (mild) to 10 (the worst pain you can imagine). But she felt much better now; her pain was maybe a 1 or 2. In fact, she was hungry and asked the young doctor if she would be able to eat soon. Maybe soon, Dr. Merai told her, but not yet.

Still, she had clearly improved drastically over the course of her night in the hospital. When she first arrived, her blood pressure had been very low and her heart racing. Now, both were in the normal range.

On physical exam, the patient had a long scar down the middle of her belly from her surgery the year before. And her abdomen was quite tender. However, there wasn’t any distention, and there were no masses, and she had normal bowel sounds. The rest of her exam was unremarkable.

Worrisome Test Results

Here was the problem: Although the patient looked well, her test results suggested that she was actually quite sick. Her blood tests showed an elevated white blood cell count, suggesting an infection or other type of inflammation. Her blood contained elevated levels of lipase, an enzyme made by the pancreas and used in digestion.

Did the she have pancreatitis? It didn’t really fit. And the CT scan was even more concerning. It showed extensive swelling in the walls of her small intestines. The walls were so swollen they almost closed off the entire intestinal tract. She also had fluid in her abdominal cavity. The radiologist said the findings were consistent with either an infection or possibly a loss of blood flow to the bowel, both worrisome possibilities.

Although we are taught that study results are less dependable than the clinical assessment of the patient, it was hard not to be concerned about a patient with studies like this. The resident realized that it was going to take some work to figure out what was going on with this woman’s intermittent episodes of pain. Lots of doctors had already failed.

First, she wasn’t about to feed the patient. It might trigger the pain and vomiting. And besides, she might need tests that required an empty stomach. She gave the intern the job of getting copies of the patient’s records from the other hospitals where she had been treated. They needed to know what was already known.

A Range of Possibilities

It seemed unlikely that this was an infection. Could this patient, or anyone, have the same infection four times? But unlikely wasn’t impossible. So Dr. Merai started her on antibiotics.

She asked the surgical team to see the patient. She looked too well to have a loss of blood flow to her guts, but that would be a surgical emergency and Dr. Merai wasn’t taking any chances. She also asked the G.I. service to see the patient, to help them figure out what they might not even be thinking of.

You can see the intern’s admission note here.

The surgeons agreed that she didn’t need to go to the operating room. They would follow her exam and, if she got worse, reconsider their decision.

The G.I. fellow recommended looking for other causes of the inflammation. Could this be an autoimmune disease? He also suggested that the CT scan be repeated, this time with intravenous contrast to allow them to see the blood supply to the intestines. And since she looked so good, she could try clear fluids. If that didn’t make her throw up, she could try real food.

You can see the G.I. fellow’s note here.

Two Pictures Tell a Crazy Story

The second scan was done the following morning, about 36 hours after the first one. The radiologist was amazed. It hardly looked like the same woman’s guts. The bowel wall swelling that nearly occluded the G.I. tract was nearly gone. The abdominal fluid was also gone.

You can see images from the two CT scans – the earlier one on the left, and the later one on the right — here.

Her white count was back to normal. So was her lipase. And so, apparently, was the patient. When Dr. Merai and Dr. Schoettler saw her that next morning, she was eager for regular food, having tolerated the clear liquid diet. What could she possibly have that would get better this quickly?

Try to solve the mystery , add a comment to see the correct answer in the hidden box below

***Hidden content cannot be quoted.***

Source : New York Times Cases
I chose one case to you , you will find more cases ther
Reversible Ischemia Of Intestine Due to emboli
Click to expand...

danica · Jan 2, 2014

Emanuele said: ↑

?
Click to expand...

dilki punchihewa · Jan 2, 2014

side effect of lisinopril
commonest side effects associated with GIT are abdominal pain, nausea vomiting and diarrhea.

Sujay Shanker · Jan 2, 2014

Bowel ischaemia, this would explain the elevated lipase, and reversible swelling of the intestinal, probably due to spasm of a mesentric vessel.

estel24 · Jan 2, 2014

?

Dark-Knight · Jan 2, 2014

Egyptian Doctor said: ↑

The Challenge: Can you solve a medical mystery involving a previously healthy 47-year-old woman who for the past two years has had episodes of abdominal pain, nausea and vomiting so severe she has needed to be hospitalized?

We will provide some of the notes and imaging tests ordered by doctors who saw this patient. The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped many of the doctors at one of the great hospitals of the world.

The Patient’s Story

“Do you want me to pull over?” the middle-aged man asked anxiously as he glanced over at his wife. She had placed a plastic bag tightly against her mouth as her shoulders and upper body contracted in silent paroxysms of vomiting.

She shook her head once the spasms subsided, and he returned his full attention to the twilit highway before him. He knew that the most important thing he could do for his wife was to get her to the hospital as quickly as possible.

She had been fine that morning, working with their three children, whom she had been home-schooling. Then, late that afternoon, she began vomiting, over and over again, long after she had eliminated everything she had in her system. She and her children had eaten chicken salad for lunch, but everyone else felt fine.

And at this point it was a sadly familiar event. She had had several episodes like this over the past two years and had already spent weeks in various hospitals as doctor after doctor tried to understand where these paroxysms of terrible pain and incessant vomiting came from and how to make them stop.

Another Hospital Visit

Dr. Poonam Merai, the resident on call that day at the University of Chicago Medical Center, sighed when she got the text from the emergency room alerting her about a 47-year-old woman with abdominal pain and uncontrolled vomiting. It was only 10 in the morning, and they had already had quite a few patient admissions. It was going to be a busy day.

She flipped through the woman’s thin chart, then turned to her intern, Dr. Nathan Schoettler. “We might as well go see her; there’s not much in here,” she said as she returned the clipboard to its slot.

You can review the E.R. resident’s note here.

The patient’s room was dark when the two doctors-in-training arrived. Dr. Merai knocked on the open door and quickly introduced herself and the intern. “May I turn on the light?” she asked.

The patient rolled over to face the two young doctors and gave them a smile. Sure, she told them, why not? She told them about the events of the day before. She and her husband had arrived at the hospital in late afternoon and had been talking and getting tested until the wee hours of the morning. What more did they need to know?

The Patient’s History

It started nearly two years earlier, the woman told Dr. Merai. She had been at work — she was a clerk in a bank then — and had suddenly started vomiting. As she made her way back to her desk, she felt weak and unsteady and fainted. Or that’s what everybody told her, because the next thing she knew, she was in an ambulance on the way to the hospital.

There, a CT scan showed that her small intestines were inflamed. The doctors said she might have Crohn’s disease. But after a couple of days, she started to feel better and went home. Because she felt O.K., she never followed up.

And then, it happened again — nine months later. Again she was rushed to the hospital. Again a CT scan showed an abnormality in the small intestines. This time the doctors were so worried they took her straight into the operating room.

“They thought my guts were tangled up in knots,” she told the doctor. But when she woke up, the surgeon told her that he was amazed to see that her insides were pristine. There was swelling and a lot of fluid in her belly, but no twisting, and no infection. And nothing to take out.

At that hospital she had an endoscopy so doctors could look at her stomach and upper G.I. tract and a colonoscopy to look at the other end. Those exams were normal. They considered transferring her to the University of Chicago, the main medical center in the area, but after a few days on antibiotics, she got better and went home.

Six months later it happened again. She went to a third hospital and had another endoscopy, and another colonoscopy. Again, some small bowel inflammation was seen, and again there was talk of sending her to the University of Chicago. But again, she got better with I.V. fluids and antibiotics, and so she was sent home.

This last time, when the pain and vomiting started, she and her husband were determined to go straight to the University of Chicago. And so, here she was.

A Patient Who Looks Basically Well

Other than these crazy episodes of pain and vomiting, she felt quite well. She was careful with her diet and exercised regularly. And she was pretty good about taking the medications she was prescribed for her diabetes and high blood pressure. She didn’t smoke or drink, and when she wasn’t working with her children, she worked with the students at a local elementary school in their after-school program.

On exam, the doctor noted that the patient was a friendly and well-appearing African-American woman. Her pain had been intolerable when she first arrived — an 8 or 9 on a scale that went from 1 (mild) to 10 (the worst pain you can imagine). But she felt much better now; her pain was maybe a 1 or 2. In fact, she was hungry and asked the young doctor if she would be able to eat soon. Maybe soon, Dr. Merai told her, but not yet.

Still, she had clearly improved drastically over the course of her night in the hospital. When she first arrived, her blood pressure had been very low and her heart racing. Now, both were in the normal range.

On physical exam, the patient had a long scar down the middle of her belly from her surgery the year before. And her abdomen was quite tender. However, there wasn’t any distention, and there were no masses, and she had normal bowel sounds. The rest of her exam was unremarkable.

Worrisome Test Results

Here was the problem: Although the patient looked well, her test results suggested that she was actually quite sick. Her blood tests showed an elevated white blood cell count, suggesting an infection or other type of inflammation. Her blood contained elevated levels of lipase, an enzyme made by the pancreas and used in digestion.

Did the she have pancreatitis? It didn’t really fit. And the CT scan was even more concerning. It showed extensive swelling in the walls of her small intestines. The walls were so swollen they almost closed off the entire intestinal tract. She also had fluid in her abdominal cavity. The radiologist said the findings were consistent with either an infection or possibly a loss of blood flow to the bowel, both worrisome possibilities.

Although we are taught that study results are less dependable than the clinical assessment of the patient, it was hard not to be concerned about a patient with studies like this. The resident realized that it was going to take some work to figure out what was going on with this woman’s intermittent episodes of pain. Lots of doctors had already failed.

First, she wasn’t about to feed the patient. It might trigger the pain and vomiting. And besides, she might need tests that required an empty stomach. She gave the intern the job of getting copies of the patient’s records from the other hospitals where she had been treated. They needed to know what was already known.

A Range of Possibilities

It seemed unlikely that this was an infection. Could this patient, or anyone, have the same infection four times? But unlikely wasn’t impossible. So Dr. Merai started her on antibiotics.

She asked the surgical team to see the patient. She looked too well to have a loss of blood flow to her guts, but that would be a surgical emergency and Dr. Merai wasn’t taking any chances. She also asked the G.I. service to see the patient, to help them figure out what they might not even be thinking of.

You can see the intern’s admission note here.

The surgeons agreed that she didn’t need to go to the operating room. They would follow her exam and, if she got worse, reconsider their decision.

The G.I. fellow recommended looking for other causes of the inflammation. Could this be an autoimmune disease? He also suggested that the CT scan be repeated, this time with intravenous contrast to allow them to see the blood supply to the intestines. And since she looked so good, she could try clear fluids. If that didn’t make her throw up, she could try real food.

You can see the G.I. fellow’s note here.

Two Pictures Tell a Crazy Story

The second scan was done the following morning, about 36 hours after the first one. The radiologist was amazed. It hardly looked like the same woman’s guts. The bowel wall swelling that nearly occluded the G.I. tract was nearly gone. The abdominal fluid was also gone.

You can see images from the two CT scans – the earlier one on the left, and the later one on the right — here.

Her white count was back to normal. So was her lipase. And so, apparently, was the patient. When Dr. Merai and Dr. Schoettler saw her that next morning, she was eager for regular food, having tolerated the clear liquid diet. What could she possibly have that would get better this quickly?

Try to solve the mystery , add a comment to see the correct answer in the hidden box below

***Hidden content cannot be quoted.***

Source : New York Times Cases
I chose one case to you , you will find more cases there
Click to expand...

adewald123 · Jan 2, 2014

leaning toward IBS or celiac disease

Amany Doraidy · Jan 2, 2014

emboli to superior mesenteric artery

Elizabeth Brzeski · Jan 2, 2014

Egyptian Doctor said: ↑

The Challenge: Can you solve a medical mystery involving a previously healthy 47-year-old woman who for the past two years has had episodes of abdominal pain, nausea and vomiting so severe she has needed to be hospitalized?

We will provide some of the notes and imaging tests ordered by doctors who saw this patient. The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped many of the doctors at one of the great hospitals of the world.

The Patient’s Story

“Do you want me to pull over?” the middle-aged man asked anxiously as he glanced over at his wife. She had placed a plastic bag tightly against her mouth as her shoulders and upper body contracted in silent paroxysms of vomiting.

She shook her head once the spasms subsided, and he returned his full attention to the twilit highway before him. He knew that the most important thing he could do for his wife was to get her to the hospital as quickly as possible.

She had been fine that morning, working with their three children, whom she had been home-schooling. Then, late that afternoon, she began vomiting, over and over again, long after she had eliminated everything she had in her system. She and her children had eaten chicken salad for lunch, but everyone else felt fine.

And at this point it was a sadly familiar event. She had had several episodes like this over the past two years and had already spent weeks in various hospitals as doctor after doctor tried to understand where these paroxysms of terrible pain and incessant vomiting came from and how to make them stop.

Another Hospital Visit

Dr. Poonam Merai, the resident on call that day at the University of Chicago Medical Center, sighed when she got the text from the emergency room alerting her about a 47-year-old woman with abdominal pain and uncontrolled vomiting. It was only 10 in the morning, and they had already had quite a few patient admissions. It was going to be a busy day.

She flipped through the woman’s thin chart, then turned to her intern, Dr. Nathan Schoettler. “We might as well go see her; there’s not much in here,” she said as she returned the clipboard to its slot.

You can review the E.R. resident’s note here.

The patient’s room was dark when the two doctors-in-training arrived. Dr. Merai knocked on the open door and quickly introduced herself and the intern. “May I turn on the light?” she asked.

The patient rolled over to face the two young doctors and gave them a smile. Sure, she told them, why not? She told them about the events of the day before. She and her husband had arrived at the hospital in late afternoon and had been talking and getting tested until the wee hours of the morning. What more did they need to know?

The Patient’s History

It started nearly two years earlier, the woman told Dr. Merai. She had been at work — she was a clerk in a bank then — and had suddenly started vomiting. As she made her way back to her desk, she felt weak and unsteady and fainted. Or that’s what everybody told her, because the next thing she knew, she was in an ambulance on the way to the hospital.

There, a CT scan showed that her small intestines were inflamed. The doctors said she might have Crohn’s disease. But after a couple of days, she started to feel better and went home. Because she felt O.K., she never followed up.

And then, it happened again — nine months later. Again she was rushed to the hospital. Again a CT scan showed an abnormality in the small intestines. This time the doctors were so worried they took her straight into the operating room.

“They thought my guts were tangled up in knots,” she told the doctor. But when she woke up, the surgeon told her that he was amazed to see that her insides were pristine. There was swelling and a lot of fluid in her belly, but no twisting, and no infection. And nothing to take out.

At that hospital she had an endoscopy so doctors could look at her stomach and upper G.I. tract and a colonoscopy to look at the other end. Those exams were normal. They considered transferring her to the University of Chicago, the main medical center in the area, but after a few days on antibiotics, she got better and went home.

Six months later it happened again. She went to a third hospital and had another endoscopy, and another colonoscopy. Again, some small bowel inflammation was seen, and again there was talk of sending her to the University of Chicago. But again, she got better with I.V. fluids and antibiotics, and so she was sent home.

This last time, when the pain and vomiting started, she and her husband were determined to go straight to the University of Chicago. And so, here she was.

A Patient Who Looks Basically Well

Other than these crazy episodes of pain and vomiting, she felt quite well. She was careful with her diet and exercised regularly. And she was pretty good about taking the medications she was prescribed for her diabetes and high blood pressure. She didn’t smoke or drink, and when she wasn’t working with her children, she worked with the students at a local elementary school in their after-school program.

On exam, the doctor noted that the patient was a friendly and well-appearing African-American woman. Her pain had been intolerable when she first arrived — an 8 or 9 on a scale that went from 1 (mild) to 10 (the worst pain you can imagine). But she felt much better now; her pain was maybe a 1 or 2. In fact, she was hungry and asked the young doctor if she would be able to eat soon. Maybe soon, Dr. Merai told her, but not yet.

Still, she had clearly improved drastically over the course of her night in the hospital. When she first arrived, her blood pressure had been very low and her heart racing. Now, both were in the normal range.

On physical exam, the patient had a long scar down the middle of her belly from her surgery the year before. And her abdomen was quite tender. However, there wasn’t any distention, and there were no masses, and she had normal bowel sounds. The rest of her exam was unremarkable.

Worrisome Test Results

Here was the problem: Although the patient looked well, her test results suggested that she was actually quite sick. Her blood tests showed an elevated white blood cell count, suggesting an infection or other type of inflammation. Her blood contained elevated levels of lipase, an enzyme made by the pancreas and used in digestion.

Did the she have pancreatitis? It didn’t really fit. And the CT scan was even more concerning. It showed extensive swelling in the walls of her small intestines. The walls were so swollen they almost closed off the entire intestinal tract. She also had fluid in her abdominal cavity. The radiologist said the findings were consistent with either an infection or possibly a loss of blood flow to the bowel, both worrisome possibilities.

Although we are taught that study results are less dependable than the clinical assessment of the patient, it was hard not to be concerned about a patient with studies like this. The resident realized that it was going to take some work to figure out what was going on with this woman’s intermittent episodes of pain. Lots of doctors had already failed.

First, she wasn’t about to feed the patient. It might trigger the pain and vomiting. And besides, she might need tests that required an empty stomach. She gave the intern the job of getting copies of the patient’s records from the other hospitals where she had been treated. They needed to know what was already known.

A Range of Possibilities

It seemed unlikely that this was an infection. Could this patient, or anyone, have the same infection four times? But unlikely wasn’t impossible. So Dr. Merai started her on antibiotics.

She asked the surgical team to see the patient. She looked too well to have a loss of blood flow to her guts, but that would be a surgical emergency and Dr. Merai wasn’t taking any chances. She also asked the G.I. service to see the patient, to help them figure out what they might not even be thinking of.

You can see the intern’s admission note here.

The surgeons agreed that she didn’t need to go to the operating room. They would follow her exam and, if she got worse, reconsider their decision.

The G.I. fellow recommended looking for other causes of the inflammation. Could this be an autoimmune disease? He also suggested that the CT scan be repeated, this time with intravenous contrast to allow them to see the blood supply to the intestines. And since she looked so good, she could try clear fluids. If that didn’t make her throw up, she could try real food.

You can see the G.I. fellow’s note here.

Two Pictures Tell a Crazy Story

The second scan was done the following morning, about 36 hours after the first one. The radiologist was amazed. It hardly looked like the same woman’s guts. The bowel wall swelling that nearly occluded the G.I. tract was nearly gone. The abdominal fluid was also gone.

You can see images from the two CT scans – the earlier one on the left, and the later one on the right — here.

Her white count was back to normal. So was her lipase. And so, apparently, was the patient. When Dr. Merai and Dr. Schoettler saw her that next morning, she was eager for regular food, having tolerated the clear liquid diet. What could she possibly have that would get better this quickly? parasite

Try to solve the mystery , add a comment to see the correct answer in the hidden box below

***Hidden content cannot be quoted.***

Source : New York Times Cases
I chose one case to you , you will find more cases there
Click to expand...

Parasite

Carlos T. · Jan 2, 2014

Intestinal angioedema

melix88 · Jan 2, 2014

inflammatory bowel disease

Janne V · Jan 2, 2014

No idea?

claudiateles · Jan 2, 2014

Dr.Ruhid said: ↑

Acute intermittent porphyria
Click to expand...

´that´s what I think too.

Dr Mona · Jan 2, 2014

Egyptian Doctor said: ↑

The Challenge: Can you solve a medical mystery involving a previously healthy 47-year-old woman who for the past two years has had episodes of abdominal pain, nausea and vomiting so severe she has needed to be hospitalized?

We will provide some of the notes and imaging tests ordered by doctors who saw this patient. The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped many of the doctors at one of the great hospitals of the world.

The Patient’s Story

“Do you want me to pull over?” the middle-aged man asked anxiously as he glanced over at his wife. She had placed a plastic bag tightly against her mouth as her shoulders and upper body contracted in silent paroxysms of vomiting.

She shook her head once the spasms subsided, and he returned his full attention to the twilit highway before him. He knew that the most important thing he could do for his wife was to get her to the hospital as quickly as possible.

She had been fine that morning, working with their three children, whom she had been home-schooling. Then, late that afternoon, she began vomiting, over and over again, long after she had eliminated everything she had in her system. She and her children had eaten chicken salad for lunch, but everyone else felt fine.

And at this point it was a sadly familiar event. She had had several episodes like this over the past two years and had already spent weeks in various hospitals as doctor after doctor tried to understand where these paroxysms of terrible pain and incessant vomiting came from and how to make them stop.

Another Hospital Visit

Dr. Poonam Merai, the resident on call that day at the University of Chicago Medical Center, sighed when she got the text from the emergency room alerting her about a 47-year-old woman with abdominal pain and uncontrolled vomiting. It was only 10 in the morning, and they had already had quite a few patient admissions. It was going to be a busy day.

She flipped through the woman’s thin chart, then turned to her intern, Dr. Nathan Schoettler. “We might as well go see her; there’s not much in here,” she said as she returned the clipboard to its slot.

You can review the E.R. resident’s note here.

The patient’s room was dark when the two doctors-in-training arrived. Dr. Merai knocked on the open door and quickly introduced herself and the intern. “May I turn on the light?” she asked.

The patient rolled over to face the two young doctors and gave them a smile. Sure, she told them, why not? She told them about the events of the day before. She and her husband had arrived at the hospital in late afternoon and had been talking and getting tested until the wee hours of the morning. What more did they need to know?

The Patient’s History

It started nearly two years earlier, the woman told Dr. Merai. She had been at work — she was a clerk in a bank then — and had suddenly started vomiting. As she made her way back to her desk, she felt weak and unsteady and fainted. Or that’s what everybody told her, because the next thing she knew, she was in an ambulance on the way to the hospital.

There, a CT scan showed that her small intestines were inflamed. The doctors said she might have Crohn’s disease. But after a couple of days, she started to feel better and went home. Because she felt O.K., she never followed up.

And then, it happened again — nine months later. Again she was rushed to the hospital. Again a CT scan showed an abnormality in the small intestines. This time the doctors were so worried they took her straight into the operating room.

“They thought my guts were tangled up in knots,” she told the doctor. But when she woke up, the surgeon told her that he was amazed to see that her insides were pristine. There was swelling and a lot of fluid in her belly, but no twisting, and no infection. And nothing to take out.

At that hospital she had an endoscopy so doctors could look at her stomach and upper G.I. tract and a colonoscopy to look at the other end. Those exams were normal. They considered transferring her to the University of Chicago, the main medical center in the area, but after a few days on antibiotics, she got better and went home.

Six months later it happened again. She went to a third hospital and had another endoscopy, and another colonoscopy. Again, some small bowel inflammation was seen, and again there was talk of sending her to the University of Chicago. But again, she got better with I.V. fluids and antibiotics, and so she was sent home.

This last time, when the pain and vomiting started, she and her husband were determined to go straight to the University of Chicago. And so, here she was.

A Patient Who Looks Basically Well

Other than these crazy episodes of pain and vomiting, she felt quite well. She was careful with her diet and exercised regularly. And she was pretty good about taking the medications she was prescribed for her diabetes and high blood pressure. She didn’t smoke or drink, and when she wasn’t working with her children, she worked with the students at a local elementary school in their after-school program.

On exam, the doctor noted that the patient was a friendly and well-appearing African-American woman. Her pain had been intolerable when she first arrived — an 8 or 9 on a scale that went from 1 (mild) to 10 (the worst pain you can imagine). But she felt much better now; her pain was maybe a 1 or 2. In fact, she was hungry and asked the young doctor if she would be able to eat soon. Maybe soon, Dr. Merai told her, but not yet.

Still, she had clearly improved drastically over the course of her night in the hospital. When she first arrived, her blood pressure had been very low and her heart racing. Now, both were in the normal range.

On physical exam, the patient had a long scar down the middle of her belly from her surgery the year before. And her abdomen was quite tender. However, there wasn’t any distention, and there were no masses, and she had normal bowel sounds. The rest of her exam was unremarkable.

Worrisome Test Results

Here was the problem: Although the patient looked well, her test results suggested that she was actually quite sick. Her blood tests showed an elevated white blood cell count, suggesting an infection or other type of inflammation. Her blood contained elevated levels of lipase, an enzyme made by the pancreas and used in digestion.

Did the she have pancreatitis? It didn’t really fit. And the CT scan was even more concerning. It showed extensive swelling in the walls of her small intestines. The walls were so swollen they almost closed off the entire intestinal tract. She also had fluid in her abdominal cavity. The radiologist said the findings were consistent with either an infection or possibly a loss of blood flow to the bowel, both worrisome possibilities.

Although we are taught that study results are less dependable than the clinical assessment of the patient, it was hard not to be concerned about a patient with studies like this. The resident realized that it was going to take some work to figure out what was going on with this woman’s intermittent episodes of pain. Lots of doctors had already failed.

First, she wasn’t about to feed the patient. It might trigger the pain and vomiting. And besides, she might need tests that required an empty stomach. She gave the intern the job of getting copies of the patient’s records from the other hospitals where she had been treated. They needed to know what was already known.

A Range of Possibilities

It seemed unlikely that this was an infection. Could this patient, or anyone, have the same infection four times? But unlikely wasn’t impossible. So Dr. Merai started her on antibiotics.

She asked the surgical team to see the patient. She looked too well to have a loss of blood flow to her guts, but that would be a surgical emergency and Dr. Merai wasn’t taking any chances. She also asked the G.I. service to see the patient, to help them figure out what they might not even be thinking of.

You can see the intern’s admission note here.

The surgeons agreed that she didn’t need to go to the operating room. They would follow her exam and, if she got worse, reconsider their decision.

The G.I. fellow recommended looking for other causes of the inflammation. Could this be an autoimmune disease? He also suggested that the CT scan be repeated, this time with intravenous contrast to allow them to see the blood supply to the intestines. And since she looked so good, she could try clear fluids. If that didn’t make her throw up, she could try real food.

You can see the G.I. fellow’s note here.

Two Pictures Tell a Crazy Story

The second scan was done the following morning, about 36 hours after the first one. The radiologist was amazed. It hardly looked like the same woman’s guts. The bowel wall swelling that nearly occluded the G.I. tract was nearly gone. The abdominal fluid was also gone.

You can see images from the two CT scans – the earlier one on the left, and the later one on the right — here.

Her white count was back to normal. So was her lipase. And so, apparently, was the patient. When Dr. Merai and Dr. Schoettler saw her that next morning, she was eager for regular food, having tolerated the clear liquid diet. What could she possibly have that would get better this quickly?

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Source : New York Times Cases
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Saleh Hammad · Jan 2, 2014

...?

mohammed mahmoud · Jan 2, 2014

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Renato · Jan 2, 2014

Autoimmune pancreatitis

Aron Rodrigues · Jan 2, 2014

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