the doctor is in

We start this session in the office with a little pissed off attitude. “Why?” you ask. “Let me tell you,” I respond.

I get these case studies and I have real patients with real problems (dicks falling off, aliens in butts (that one is coming soon), etc.), albeit all in my virtual medical practice. I get it – I’m not a “real” doctor, I just play one on the internet. But still, that guy’s dick was going to fall off, that cold butt would be numb by now if I didn’t prescribe a hot shower and a good spanking.

Well, I open this file, jot out my diagnosis, give the guy a script for weed and speed, go to the drug store to fill it, come home, and get toasted and hyped. As while I am scratching the fricking thousands of gnats off of the wallpaper, and also gathering the carcasses to top my brownies that are baking (protein supplement), I decided on a lark to check the “real” answer written by “real” docs – as if they actually know what the hell they are talking about. What I did find? You won’t believe it! I am so pissed! They added more data! A-holes.

I have watched precisely one Hercule Periot episode. One. I am an old Columbo fan. Have seen about every one a dozen times. My hero. So I was curious about this Periot guy. I never liked men that act as he does. Character or not, he makes me want to act out. So the show goes on – the crime, the investigation, the big finale – and what happens? As he is explaining how he “solved” the murder, he added data! He added data! You don’t add information when you give your solution. It’s like a rule. That was 15 or 20 years ago. I am still pissed about it. I can be real anal about some things.

So when I felt like reading the junior varsity’s diagnosis of this guy and saw that they added data I almost quit practicing medicine again. But I have a responsibility to my patients, and I took the Hippopotamus Oath sometime or another, so here I am.

Let’s look at some pics. Here’s the one they shows us in the background.


The guy (presumably, could be a chick), has a problem immediately apparent. See it? The dude’s must be shaped like a grotesque pear! Very thin on top. Can see right through him. Then with his heart in the middle, you can see his butt pushing right up to it! See his cheeks? That’s really gross. Heart looks kinda big, too. Is having a big heart a bad thing? They always say it’s ok, but this one may be swollen because it’s chaffed or something from rubbing up against his butt cheeks.

Note: “Relocate butt.”

His bones look kinda thin, too. Note: “Prescribe calcium supplement.”

And now, the pic they were hiding from us (I won’t treat you, my team of residents, in the same despicable manner as Dr. Periot treated me).


Ut oh! Another misfile? Looks like Joe Camel all dolled up to make himself feel pretty got his booty caught on a night-surveillance camera. Thought no one would be looking, eh, Josephine? You know, pal, there is one rule in this world: When you want to look pretty, and you’ve got a pump-action yogurt chucker sitting atop a mud flap all stuck inside your tummy-tucker pantyhose, you stay inside with the doors locked and windows blocked. It’s like a rule. OK?

I can’t believe it’s another misfile. Let’s look closer. Yep, misfile. Joe Camel. Let’s go to the patient …

BACKGROUND. A 27-year-old man presents to the emergency department with a 3-day history of worsening epigastric pain and nonbilious vomiting (Oh, this sounds bad. I better put on one of this ear things with the cold silver front that the “real” docs lick and then put on a woman’s breast. Note: “Put morgue on alert – incoming.”). His bowel movements were normal until the day of presentation (“until”), when they turned black and sticky (I’m gonna puke.). He denies having any hematemesis (so would I. What kind of pervert to do think I am? Hema-what? WTF is that?), fever, chills, or any other associated symptoms, as well as any history of prior surgeries or medical problems. He has taken no medications recently except for Pepto-Bismol, which made the pain worse (did you check the expiration date? That stuff tastes like shit on a good day; can you imagine after the half-life has expired?). He does not smoke tobacco but consumes 4 beers each day (that’s almost 1,500 beers a year! What was that word up there … oh yeah, “epigastric.” Means, “beer coming out the wazoo”). He denies any illicit drug use (why? He’s thoroughly liquid. This boy spends almost a $1,000 a year on beer! No wonder his ass is so big).

On physical examination, his oral temperature (oh, c’mon, have some balls – stick it up his ass. Oh yeah, you’d have to work your arm up to the elbow just to find the entry point. Oh, dry heaves coming!)is 98.6°F (37.0°C). His pulse has a regular rhythm with a rate of 88 bpm. His blood pressure is 198/88 mm Hg. He is noted to be in mild distress secondary to his epigastric discomfort (hurts having all that beer coming out your wazoo, doesn’t it?). The examination of his head and neck, including a check for icteric sclerae (is that like code for head lice?), is normal. His lungs are clear to auscultation with normal respiratory effort (sure, and remember the homeless guy that they crammed something down his throat to make him gag? Not this guy – he’s got insurance!). A 1/6 soft systolic ejection murmur is detected (“Systolic.” I;ve heard that word before. It’s a medical term of some kind.). His S1 and S2 heart sounds are normal. His abdomen is soft (“fat”) but tender to deep palpation in the epigastric region (the “wazoo” region). The rectal exam (oh no! Going in! Better tie a rope around your waist. Gas mask!) reveals normal tone and black, guaiac-negative stool (I really do not like the sound of “gualac-negative.” It’s like, “we did a scrotum check, and it came back ‘testicular-negative.’ We’re sorry, sir, you have no balls.”). The peripheral arterial pulses in the lower extremities are palpable but diminished when compared to the pulses in the upper extremities (that’s normal, ain’t it? Nearer thy god to thee?).

The laboratory analysis, including a complete blood count and a basic metabolic panel, is normal; however, his serum amylase and lipase levels are elevated, at 240 U/L (normal range, 30-110 U/L) and 2118 U/L (normal range, 46-218 U/L), respectively (Hey, Joe, you got the extension for the morgue? 221? Thanks.). The patient is diagnosed with alcohol-induced pancreatitis (surprise, surprise) and treated in the ED with bowel rest, intravenous fluids, antiemetics, and generous doses of intravenous opiate analgesics (gotta love ERs. Here’s some opium, a generous amount. Who’s leg you gotta hump to get this script?). The patient is to be admitted to the hospital for continued bowel rest and intravenous fluid therapy for complete resolution of his pancreatitis; however, despite having his pain eased, the patient is noted to have a persistently elevated systolic blood pressure in the 190-199 range (she’s gonna blow!) and a diastolic blood pressure in the 90-109 range. When further queried for his past medical history (because we think you lied the first time) and a thorough review of systems, the patient does not recall ever having had his blood pressure checked, although he does report that he frequently experiences cramping in his legs (sure you don’t smoke?) and sometimes feels as if his feet are “cold.” (Got socks?)

A posteroanterior chest radiograph is obtained (Image 1). (Hollow guy, big butt.)

What is the most likely cause of this patient’s hypertension, and what further testing should be performed? (Beer. Put him a treadmill until he drops like a stone, then call the morgue. Should take no more than 7 minutes.)

HINT. The next step should be to check the blood pressure in the lower extremities.

ANSWER. Aortic coarctation: The patient’s hypertension and murmur are likely caused by a previously undiagnosed coarctation of the aorta (Beer-induced heart malfunction. Would have been better off smoking. At least his butt would be a normal size.). The chest radiograph demonstrates an enlarged collateral intercostal arterial circulation that has caused notching of the inferior-posterior rib margins, which is supportive of the diagnosis (JV clowns. The “notching” is because his ass has rubbed his heart. The resulting chaffing has enlarged the cardiac organ to such a degree that it is now affecting his ribs.). Magnetic resonance angiography (MRA) confirms the presence of a postductal aortic coarctation (Image 2). (Joe Camel in a dress.)

(You can read more … I’m done.)

Coarctation of the aorta is a congenital condition that results in narrowing of a segment of the aorta. It was first described by Giovanni Morgagni in 1760. Historically, coarctation of the aorta was classified as preductal (before the origin of the ductus arteriosus) or juxtaductal (distal to the origin of the ductus arteriosus). More recently, the latter designation has been abandoned for the term postductal. The postductal form is the most common type of coarctation of the aorta. Coarctation of the aorta constitutes approximately 6-8% of all congenital heart diseases in infants. It is most frequently associated with other forms of congenital heart disease, such as ventricular septal defects, patent ductus arteriosus, bicuspid aortic valves, and aortic stenoses; however, it may also appear as an isolated condition. It is more common in males than in females; in patients with ovarian agenesis (Turner syndrome), it is particularly common.

Patients diagnosed with coarctation of the aorta in infancy usually have a combination of other heart anomalies that can lead to overt congestive heart failure. Those patients presenting beyond infancy, such as in this case, often have vague symptoms that may include headaches, a propensity to nose bleeds, leg cramps, and cold feet. Hypertension is usually present and leads to further in-depth testing. The hallmark physical sign of postductal coarctation is that blood pressure in the arms is at least 20 mm Hg higher than it is in the lower extremities (normally blood pressure in the lower extremities is slightly higher than in the upper extremities). A systolic or continuous murmur in the infrascapular or infraclavicular area also may suggest the presence of this anomaly. Additional murmurs may indicate the presence of associated anomalies, such as ventricular septal defects, patent ductus arteriosus, or aortic stenoses.

Chest radiography may demonstrate cardiomegaly and rib notching from the compensatory collateral intercostal arterial dilatation. The classic “figure 3” sign seen on chest radiographs occurs in at least one third of patients, and results from prestenotic dilatation of the ascending aorta followed by indentation of the aorta at the coarctation site and poststenotic dilatation of the descending aorta. The “reverse 3” or “E” sign can also be observed on barium swallow studies, resulting from matched compression of the esophagus by the dilated segments of the aorta. Signs of left ventricular hypertrophy are also often seen on electrocardiograms (ECGs). An echocardiogram is usually performed to detect any associated cardiac anomalies. MRA and cardiac catheterization may be necessary to confirm the exact location and the presence of collaterals. A gradient of more than 20% across the stenosis during cardiac catheterization indicates a severe coarctation and requires urgent intervention.

Treatment of aortic coarctation is usually surgical. Antihypertensive medication must be used with caution, as its use may lead to inadequate perfusion of the lower body and renal impairment. The best treatment strategy is admission for early repair. If left untreated, 90% of patients with aortic coarctation die by the age of 50 years, usually from hypertensive complications. Historically, surgical resection of the involved aortic segment has been the treatment of choice, and it has a high success rate. More recently, balloon dilatation and placement of endovascular stents are gaining popularity and becoming accepted forms of primary therapy, especially for patients who may be unsuitable candidates for surgery. Postoperative complications may be acute or delayed and include persistent hypertension, recoarctation, and aortic aneurysms, among others.

This patient had an echocardiogram that failed to reveal any associated cardiac defects. He was referred for surgical intervention and underwent successful resection of the coarcted aortic segment after resolution of his associated pancreatitis, the initial reason for his presentation and admission.