the doctor is in march 2008

We gots a sick boy ... right to it!

Near-Syncope in a 24-Year-Old Man

Background.

A 24-year-old man with no significant past medical history presents to the emergency department (ED) with a complaint of several episodes of a sensation of nearly blacking out. (Ut oh. Sounds bad. Where’s my stethoscope thingey?) The episodes have occurred about 3-4 times over the 3 days before presentation. (Un hunh. OK. Scribble, scribble. Go on. Tell me, how long did each of these episodes last?) The duration of each episode has ranged from a few minutes to over an hour. (Ok, ok. Scribble, scribble. Anything with your heart? Head?) The patient notes that he has felt his "heart beating really fast," with associated light-headedness. (Scribble, scribble. Any chest pain, shortness of breath, or nausea associated with these events?) He denies having any chest pain, shortness of breath, or nausea associated with these events. (Scribble, scribble. So, you like doing anything when this happens? You know, like, banging the misses, pulling the trouser taffy?) He cannot identify exacerbating or alleviating factors; specifically, he denies exertion as an inciting factor. (Scribble, scribble.) The remainder of his review of systems is negative except for some mild chronic shortness of breath. (Shortness of breath? Taking any meds?) The patient takes no medications at home and has no active medical conditions. (Smoke?) He smokes 2-4 packs of cigarettes per day and has done so for 5-6 years. (WHAT?!? Up to 4 packs a DAY? You throw in some weed just to change the ashtray flavor in your mouth?) He denies any illicit drug use or recent use of over-the-counter medications or herbal remedies. (You sure your heart ain’t cranked out? Anybody in your jet stream die of heart disease yet?) He has no history of any significant cardiac disease or sudden cardiac death in his family.

(NOTE TO SELF. Four packs a day. Figure 5 minutes from opening the pack to stubbing it out. 80 events at 12 per hour constant rate equals 6 hours 40 minutes a day devoted to smoking. Figure 16 hour day, that’s 42% of his waking life is smoking.)

On physical examination, the patient is afebrile (aaa—ahhhh—ahhfff-eee-br-eeeyyyeee-llleee; ahf-e-br-eye-lee), with a pulse of 65 bpm (cuz it’s so gummed up that’s it top rate), a blood pressure of 120/84 mm Hg, and a respiratory rate of 15 breaths/min (6.25 of which are laced with nicotine). His room air saturation reading is 100% (check the gauge, must be stuck). In general, he is well-appearing and in no acute distress (OK. So he bathed and isn’t whimpering. How many cigarettes has he excused himself to go smoke during your examination?). The patient's neck examination shows no jugular venous distention (yeah, did you look in his ears? Bet he’s got tar build-up in there). The heart sounds, including S1 and S2, reveal no audible murmurs, rubs, or gallops (probably sounds more like a Wrigley’s Gum Quality Assurance Department staff meeting). The apical impulse is nondisplaced and of normal impact (I have no idea what that means). The lung sounds are diminished throughout (really? Shocking!), but there are no wheezes, rales, or rhonchi. He has no edema of the lower extremities, and the distal pulses are easily palpable. All other exam findings, including a neurologic examination, are unremarkable. (You want remarkable? Tie him down for an hour and watch nicotine withdrawals hit him. Four packs a day? Crack habits are cheaper.)

The patient is placed on a cardiac monitor, and an 18-gauge intravenous (IV) catheter is inserted into the antecubital fossa (aaa-aannntt-eee – oh, forget it). Laboratory tests consisting of a complete blood count (CBC) and serum electrolytes are ordered. A portable chest radiograph reveals slight hyperinflation and hyperlucency of the lung fields (some reaction in the lungs? How surprising.), with a flattened diaphragm and central pulmonary artery enlargement (tar build-up similar to having a tile grout injected into you will tend to enlarge the receiving vessel). An electrocardiogram (ECG) is obtained (see Figure 1).


What is the diagnosis? (Hint: Pay close attention to the intervals and the QRS complex morphology.)
A. Wolff-Parkinson-White syndrome (I’d pick this one if it were Winston-Pall Mall-Marlboro syndrome)
B. Ventricular fibrillation
C. Sinus tachycardia
D. Non-sustained ventricular tachycardia

(Yeah, OK, here we go. This dude shows up smoking 4 packs a day, feels a little lightheaded, and they are going to find some fancy name for it. Wanna cure? STOP SMOKING, you idiot!)

Discussion:

Preexcitation (you see? “preexcitation.” “Pre-” nothing. It is post-four packs a day.) is characterized by an accessory pathway within the heart that conducts action potentials between the atria and ventricles outside of the normal conduction system (which conducts through the atrioventricular [AV] node-His-Purkinje system). The phenomenon was defined by Durrer et al in 1970, who stated that "preexcitation exists, if in relation to atrial events, the whole or some part of the ventricular muscle is activated earlier by the impulse originating from the atrium than would be expected if the impulse reached the ventricles by way of the normal specific conduction system only."[5] Of the various types of preexcitation syndromes, the most common is Wolff-Parkinson-White (WPW) syndrome. (Funny. A syndrome. Smoking four packs a day is a syndrome. These people are idiots. I’m done. You keep reading if you want to …)

WPW syndrome can be identified by a classic fusion QRS complex ECG pattern that is a combination of simultaneous normal conduction through the AV node and aberrant conduction through the accessory tract. This fusion QRS complex leads to particular ECG features that include a shortened PR interval (<120 msec) and a widened QRS complex with a delta wave representing preexcitation of the ventricle through the accessory pathway. The distinctive ECG pattern of the accessory pathway was initially described by Wolff, Parkinson, and White in 1930 as a bundle branch block with a short PR interval. Additionally, as mentioned, WPW syndrome is recognized as the most common form of ventricular preexcitation, although it likely represents a collection of pathologic conditions rather than a single structural abnormality.

Normal cardiac conduction of action potentials from the atria to the ventricles occurs exclusively through the AV node; the atrial impulses are subsequently propagated through a specialized conduction system (the AV-His-Purkinje system) and finally terminate in the ventricular myocardium. Action potential conduction through the AV node depends on slow inward calcium currents. In addition, the AV nodal system exhibits decremental conduction, which provides a protective effect; as the cardiac cycle is shortened (eg, the heart rate increases), there is decreased conduction through the AV node. This phenomenon limits the ventricular response to rapid atrial rates, such as those observed in atrial fibrillation or atrial flutter.

In preexcitation syndromes such as WPW, however, the action potential conducts to the ventricles at least partially through an accessory pathway termed the AV bypass tract or the bundle of Kent. Action potential propagation in the accessory pathway in WPW syndrome occurs through a rapid cellular influx of sodium. The consequence of the sodium-dependent action potential propagation mechanism is an accelerated conduction of impulses by the accessory bypass tracts, which leads to early activation of the ventricle as demonstrated by a shortened PR interval and a "slurred" QRS complex (ie, delta wave). Ventricular depolarization slowly spreads out from the bypass tract, while normal conduction that has been somewhat delayed through the AV node begins to conduct through the His-Purkinje system and spreads quickly to the remaining ventricular musculature. Although conduction velocity through the accessory pathway is faster than it is through the AV node, the accessory pathway often has a longer refractory period and, as such, is slower to recover excitability. Interestingly, the conduction of action potentials through the accessory pathway is nondecremental; therefore, the protective effect achieved by the AV node at higher heart rates is lost. These differences have important clinical implications. For example, a premature beat may conduct through the AV node normally while the accessory pathway remains refractory to conduction. The impulse then travels in a retrograde direction through the accessory pathway after ventricular depolarization, when it has recovered excitability. The consequence of this is the propagation of a reentry loop termed an orthodromic AV reciprocating tachycardia. This can then lead to rapid ventricular response rates that can degenerate into ventricular tachyarrhythmias. Rarely, antidromic tachycardias occur; conduction occurs in an anterograde direction through the accessory pathway and in a retrograde direction through the AV node.

Ventricular depolarization occurs through both the AV node-His bundle pathway and the accessory pathway; each pathway affects the ventricles by various degrees, depending on their relative activation times. As AV nodal conduction is delayed by either rapid atrial pacing or premature atrial beats, the accessory pathway contributes to a greater degree, resulting in a wider QRS morphology with an increasingly slurred delta wave. If the relative conduction time through the AV node is sufficiently delayed, total activation of the ventricle may occur through the accessory pathway.

The presence of accessory bypass tracts is not uncommon in the general population; however, less than half of the people with bypass tracts actually sustain a tachyarrhythmia. WPW syndrome affects approximately 0.15-0.2% of the general population, and of these individuals, 60-70% have no other evidence of heart disease. Mortality and morbidity associated with WPW syndrome occur as a result of associated dysrhythmias or from mistreatment of these dysrhythmias with inappropriate medications. Most studies report that the incidence of sudden death is in the 0-4% range. Men are affected more often than women,[5] accounting for 60-70% of all cases. Although this disease affects people of all ages, it is typically first recognized in children and young adults who present to the ED or their primary care physician with symptoms secondary to a dysrhythmia. Genetic mutations have been identified (by mapping genetic defects to specific loci) that account for the increased incidence of WPW syndrome in certain families.[2]

In patients with suspected WPW syndrome, evaluation should initially be directed at confirming the diagnosis and recognizing any potentially life-threatening arrhythmias. In patients with life-threatening arrhythmias, direct-current cardioversion should be immediately administered. In stable patients with tachyarrhythmias, an antiarrhythmic medication may be administered to terminate the arrhythmic episode, rather than immediately performing electrical cardioversion.

Studies have demonstrated that the best and most cost-effective treatment for patients with asymptomatic WPW syndrome is simple observation.[5] Most patients with symptomatic arrhythmias, drug-refractory WPW syndrome, or significant life-threatening arrhythmias are treated with nonpharmacologic therapy. Surgical ablation, previously the standard technique for drug-refractory WPW syndrome, has been replaced by catheter-based procedures. Compared with surgical techniques, catheter ablation has comparable success rates, lower mortality and complication rates, and improved cost-effectiveness. Moreover, newer catheter mapping systems now allow shorter procedure times. Surgical ablation, however, may be necessary in patients in whom catheter ablation has failed. Because this patient had a symptomatic tachyarrhythmia, he underwent electrophysiologic mapping followed by transvenous catheter ablation. He has remained asymptomatic since this procedure.

Patients with infrequent or minimally symptomatic arrhythmias may be treated pharmacologically. The aim of pharmacologic therapy is to alter the electrophysiologic properties, such as the refractoriness or conduction velocity of the AV node or the accessory bypass tracts.

the doctor is in ... feb 08

(I am back from a well-deserved doctor’s respite at … well, nowhere. Just been busy with my day job. We have a new case – Red and Swollen Eye in a 61-Year-Old Man. Not sure what to make of it. Let’s start with the pic.)


(Oh, my! Somebody done poked that dude in the eye with a stick or something! Must’ve hurt. What’dya think it could be? Something about this guy looks dirty to me. Let’s get some data …)

BACKGROUND
A 61-year-old man presents to the emergency department (ED) with a 5-day history of pain with associated redness and swelling in his right eye. (“Five days,” you say. Uhunh … scribble scribble … ok.)

The patient had been diagnosed with herpes zoster (is that like Herpes Complex Z? Z?!? Z is like towards the end of the alphabet. That can’t be good) a few days before this presentation; he was discharged to home with a prescription for acyclovir and hydrocodone. (AAH—AAK—PSYCH—AAHPSYCH—LOVER. Acyclovir … got it here somewhere. OK, “first-time or repeat outbreaks of genital herpes.” This boy got sexed in his eyeball. That’s disgusting.)

Since he started taking acyclovir, the pain and swelling in his eye has increased. (Good. Done go have sex involving your eyeball it oughta hurt. At least now we know it weren’t no stick that got stuck there. Damn boy, whatchu thinking? You on the other side of some sleazebag glory hole?) He also reports binocular diplopia and decreased visual acuity. (BI-nocular? He got one eye shut from a getting a dick jammed in it. The only “bi” thing around here is his sexual orientation.)

On the day of presentation, he is nauseous and vomiting (yeah, after you woke up, saw the glory hole, the line of satisfied customers … I am quite sure you were puking), and he cannot open the affected eye (stick, stick, stick, poke, poke, poke. Of course he can’t open it! Hell, he probably passed out from getting clubbed by somebody’s ankle spanker), which demonstrates ptosis (p-p-pu-TOE-s-s-s-sis) of the upper eyelid, generalized proptosis, and mild periorbital erythema with associated edema.

The right pupil is 8 mm in diameter and nonreactive to direct and indirect light. (Still trying to get the license plate off that man club that hit him.) Intraocular pressure in both eyes is normal at 12 mm Hg.

What is the diagnosis? (He got a little excited about his first gay experience, went to a bar, and became a bit too intrigued about what was on the other side of those holes in the wall. Poor guy. Still puking his guts out. He got love clubbed …)

DIAGNOSIS: (See above.) Cerebro-rhino-orbital phycomycosis (CROP)/mucormycosis. (Yeah, the only “crop” he saw was the riding kind when he had the bit in mouth up on stage. Poor dude – the first time can be so humiliating.)

(Alright, alright, we’ll let the fake docs have their say … fine. Be that way. I know how it is with people like you. You know, just a side note – I kinda HAVE to leave this other stuff in. You should see my page rankings for just god-awful diseases. I do have some fraction of a conscious, somewhere, I am sure I do. Well, maybe not, but I read a lot and I know what one looks like. So read on – just remember – they are WRONG. The guy just had a very rough first outing at the club. That’s all.) CROP is an aggressive, invasive infection that is caused by broad, nonseptate fungi with irregularly shaped hyphae from the class Phycomycetes. The genera that typically cause infection are Rhizopus, Rhizomucor, Absidia, and Basidiobolus. The spores of these fungi are ubiquitous and gain entrance to the human body through the mouth and the nose. Individuals who are immunocompetent will phagocytize these spores; therefore, they do not develop the disease.

Infection is most common in immunosuppressed persons, specifically in patients with poorly controlled diabetes mellitus (often in the setting of metabolic acidosis), and in patients receiving the iron-chelating drug deferoxamine. Unlike immunocompetent individuals, whose bodies phagocytize the spores, immunocompromised patients have massive spore proliferation. Mucormycosis is described almost exclusively in patients with compromised immune systems or metabolic abnormalities. The spores attach to the nasal or oral mucosa, where massive germination and hyphae formation occur, allowing the fungus to directly invade the blood vessels. Areas of ischemic infarction and necrosis are seen in the infected tissue. The fungi invade the blood vessel lumina and cause thrombosis through inflammatory occlusion. Infection usually begins in the nasal cavity and the maxillary sinuses, followed by direct invasion of contiguous structures, such as the palate, the orbits, the ethmoid sinuses, and the brain. Orbital involvement occurs when the ethmoid sinuses are affected. Intracranial spread can occur through the ophthalmic artery, superior fissure, or cribriform plate.

Rhinocerebral infections are usually fulminant and have high morbidity and mortality rates, despite improved diagnostic and therapeutic interventions. Mortality rates of 30-70% are quoted in the literature, with higher mortality rates seen in older series. The mortality rate in diabetic patients appears to be lower than it is in nondiabetic patients and in patients with intracerebral involvement. Death may occur within 2 weeks if CROP is left untreated or is unsuccessfully treated. Additionally, until the 1950s, this disease was almost always fatal. Even with recovery, permanent residual effects, such as blindness and cranial nerve defects, occur in up to 70% of cases.

The clinical manifestations of CROP may include orbital and facial pain, fever, periorbital and orbital cellulitis, proptosis, purulent nasal discharge, and mucosal necrosis that appears as black eschars in the nasopharynx, the oropharynx, and the tissues surrounding the orbits and sinuses. These clinical features are not universally seen; therefore, a high index of suspicion is required. Ocular involvement leads to afferent papillary defects and loss of visual acuity. Progressive extension of necrosis into the brain can lead to cavernous sinus thrombosis and abscess formation. The patient may demonstrate an altered mental status, convulsions, aphasia, or hemiplegia.

Patients with diabetic ketoacidosis are most often affected, but opportunistic infections may also develop in association with renal deferoxamine therapy (eg, in patients with chronic renal disease) or with immunosuppression (particularly in patients with neutropenia or those receiving high-dose corticosteroid therapy).

The diagnostic study of choice is computed tomography (CT) scanning of the orbits and sinuses. In affected patients, CT scans demonstrate soft-tissue swelling, sinus mucosal thickening, and bone erosion. Intracranial and cavernous sinus involvement may also be present. Magnetic resonance imaging (MRI), if available, can show extension of the infection into the surrounding blood vessels, orbital fat, and intracranial areas. Urgent biopsy is usually indicated. Necrotic and edematous tissue with neutrophilic infiltrate is frequently seen with fungal elements (which are broad, nonseptate hyphae with branching at 90°).

The cornerstone of medical treatment for CROP is the administration of systemic amphotericin B at the highest patient-tolerable dose. Local packing of the involved mucosal membranes with an amphotericin B solution is effective for minimizing local disfigurement. When on the medication, the patient should be assessed for nephrotoxicity, as well as other systemic symptoms of toxicity, including fever, nausea and vomiting, phlebitis, anemia, and electrolyte abnormalities. Liposomal amphotericin B may be more efficacious; it is less toxic, thus allowing higher doses of the medication to be given. Additionally, local irrigation and packing of the areas to aid delivery of amphotericin to necrotic and poorly perfused tissues is recommended, because poor vascular supply may prevent systemic therapy from reaching the fungus and because local irrigation of infected tissue has been reported to be an important adjunct to treatment that may even help prevent disfiguring surgery. Treatment of the underlying disease (eg, hypoxia, acidosis, hyperglycemia, electrolyte abnormalities) and discontinuation of any immunosuppressants are also important. The physician should evaluate any steroid medication, antimetabolites, or immunosuppressants that the patient is taking, and such agents should be discontinued if appropriate. It is encouraged that the advice of an infectious disease specialist be obtained.

Aggressive, emergency surgical debridement of all necrotic tissue is necessary; sometimes, multiple procedures are needed to clear all necrotic tissue. The vaso-occlusive effect of mucormycosis leads to infrequent bleeding of the involved tissue; therefore, debridement of affected tissue until normal, well-perfused, bleeding tissue is encountered is ideal. Intraorbital irrigation of amphotericin B may be considered as an adjunct treatment. Surgery may often be disfiguring. Orbital exenteration, as well as removal of the sinuses, may be necessary. Some authors have suggested hyperbaric oxygen as an adjunctive treatment. Reconstructive surgery after complete resolution of infection should be considered.

Indeed, a multidisciplinary approach is best for the treatment of this condition. An ophthalmologist is required to evaluate for ophthalmoplegia and optic neuropathy. An oculoplastic surgeon can provide an orbital evaluation, as well as perform debridement and reconstruction. An otolaryngologist is required for biopsy or debridement of the nasal and sinus cavities. An infectious disease specialist can provide guidance for appropriate medical treatment with antifungal agents. Internal medicine specialists and endocrinologists are useful for the medical management of underlying systemic etiologies. Neurosurgery may be necessary if intracranial involvement is present. Finally, a pharmacotherapy specialist can assist with dosing of amphotericin B.

The complications of CROP include intracranial invasion, cavernous sinus thrombosis, blindness, occlusion of the central retinal artery, and airway obstruction caused by infections of the head and neck (with spread to the carotid sheath or the mediastinum through the fascial planes). The prognosis of CROP is guarded, with reported mortality rates of 30-70% (as stated earlier).

In this patient, treatment with amphotericin B was promptly initiated. CT scans of the orbits and sinuses demonstrated an air-fluid level in the right maxillary sinus, mucosal thickening of the right anterior ethmoid sinus, and preseptal cellulitis. An MRI of the head showed enhancement of the intraconal fat and rectus muscles of the right eye. The patient received emergency sinus debridement, and a biopsy was performed. Pathology demonstrated fungal angiitis and orbital inflammation that was consistent with mucormycosis. The patient underwent 3 additional operations, including exenteration of the right eye, and received hyperbaric oxygen treatments. After hospitalization for 3 weeks, he was discharged to home in good condition.

hippocrates gets dissed

In my never-ending search for truth and wisdom, I decided that as an Internet Medical Doctor, I should take some Continuing Medical Education credits. Since I have absolutely no medical training whatsoever, I decided to start at the beginning, kinda like opening the Bible at Genesis. I decided to start with the Works by Hippocrates. He’s that Oath guy, so if people swear an oath towards or about him, I figured he must be somebody.

He was a pretty important guy, so it seems. They called him the Father of Medicine, and he lived from about 460 BC to 370 BC. Ninety years is impressive for a time before flushing toilets and Dyson vacuums.

Turns out he wrote a lot, and his works are collected into something called the Hippocratic Corpus. I figure strolling through his writings should be worth a handful of CMEs.

I picked one called, Aphorisms. It is presented in Roman-numeral section and then numbered paragraphs within each section. Let’s stroll …

I.21. Those things which require to be evacuated should be evacuated, wherever they most tend, by the proper outlets. (“Evacuated … by the proper outlets.” Man, starts right in with the anal bit. Just remarkable. How did I know that was coming?)

II.11. It is easier to fill up with drink than with food. (This sounds like a proverb. “There is no ‘I’ in teamwork.” “‘Gullible’ is not in the dictionary.” “Orville Redenbacher’s brother is a colonel in the Air Force.”)

II.21. Drinking strong wine cures hunger. (“I’m hungry!’ “Shut up! Get blasted – you won’t think about it as much!”)

II.24. [Concerning acute disease] The fourth day is indicative of the seventh; the eighth is the commencement of the second week; and hence, the eleventh being the fourth of the second week, is also indicative; and again, the seventeenth is indicative, as being the fourth from the fourteenth, and the seventh from the eleventh. (Where’s my slide rule? I know I left it around here somewhere …)

II.48. In every movement of the body, whenever one begins to endure pain, it will be relieved by rest. (“Doc, it hurts when I move.” “Then stop moving.” Brilliant!)

III.10. Autumn is a bad season for persons in consumption. (Back in his day, Consumption/Tuberculosis was characterized by coughing up blood, fever, and was almost always fatal. Seems to me, Hippo, the time of year isn’t dispositive.)

V.3. A convulsion, or hiccup, supervening on a copious discharge of blood is bad. (Good rule. Got it. Thank you.)

V.34. When a pregnant woman has a violent diarrhoea, there is danger of her miscarrying. (“Dear Diary, about two months ago I got pregnant with Spyro’s child. Last week, I began to feel a quivering in my toes that worked its way the entire distance of my legs. I thought it would result in a real howitzer of an orgasm. Alas, to my dismay, the result was explosive flatulence. Now, the flatulence has given way to violent diarrhoea. What could be next? Methinks I am not well. I must stop eating hummus as very often.”)

V.72. Persons disposed to jaundice are not very subject to flatulence. (Um, OK. “Johnny, I haven’t heard you fart lately, and you look a little yellow under the gills. I think your liver is failing. I could be wrong.”)

VI.9. Broad exanthemata are not very itchy. (“Not very”? Rather loose language for a doc, eh? If it’s a rash and it was itchy when it was little, you can be damn sure it will be itchy when it spreads. “Itch” isn’t proportioned to a condition, like you only get so much “itch” per condition. The broader the condition, Hippo, the more it frickin itches.)

VI.13. Sneezing coming on, in the case of a person afflicted with hiccup, removes the hiccup. (Yes, and if you read a few posts below, sticking your fingers in his ass will also “remove the hiccup.” Surprised you didn’t come up with that.)

VI.17. It is a good thing in ophthalmy for the patient to be seized with diarrhoea. (Let’s see … “ophthalmy” is an inflammation of the membranes or coats of the eye or of the eyeball. “I can’t see nothing, doc. My eyes are all inflamed. Big time.” “Yes, they are, Spartacus, I can see that. How’s your butt?” “Hunh?” “I said, ‘how’s your butt?’” “Um, OK, I guess. I could lose a pound or two. You know it is.” “I think we need to aid in the evacuation through the proper outlets.” “Doc, it’s my eyes. My eyes are weirding out on me.” “I know, Sparty. Trust me on this one. We’ll ream you out a good one, give you a tonic to induce violent diarrhoea, and in a few days you’ll be good as new! You aren’t pregnant, are you?”)

VI.28. Eunuchs do not take the gout, nor become bald. (Now here is news you can use! The heck with that Propecia or the Gessippi Whoever with the Beverly Hills salon that hugs all his customers while he charges them $500 for the same product you can now get for $19.99 but wait order now and we’ll give you a second bottle for free who has time for all that nonsense look I don’t own the company in fact I don’t know anything about them they just agreed to give my 20% of gross if I would do this commercial so I am and stop staring at that zit above my right eyebrow I am fully aware the pancake didn’t cover it completely just buy the product you bovine freak. You want to stop hair loss or jumpstart re-stimulation or re-growth? Easy – cut your nuts off! And as an added bonus, if you chop the mud flap off within the next 15 minutes, we’ll guaranty that you’ll never get gout! “Honey, where’s the hedge clippers?”)

VI.46. Such persons as become hump-backed from asthma or cough before puberty, die. (And if it happens after puberty, people will just spend a lifetime being pointing at you and hiding their children from your view. Man, how hard do you have to cough to create a hump on your back?)

VI.53. Delirium attended with laughter is less dangerous than delirium attended with a serious mood. (“How is he, doctor?” “He’ll be fine, Ma’am. Just keep him laughing. Whatever you do, keep him laughing.”)

VII.4. A chill supervening on a sweat is not good. (I know. This happens every time I drink myself into oblivion and evacuate through all the proper outlets. I always hear this voice, “This is not good.” Voice sounds familiar. I think it is me.)

VII.14. Stupor or delirium from a blow on the head is bad. (OK. How long did it take to figure this one out? Did you use live subjects?)

VII.34. When bubbles settle on the surface of the urine, they indicate disease of the kidneys, and that the complaint will be protracted. (I always make bubbles. It’s fun!)

VII.43. A woman does not become ambidexterous. (Whew! Is the next line, “burn the witch!”?)

VII.55. When the liver is filled with water and bursts into the epiploon, in this case the belly is filled with water and the patient dies. (I think you got a little off track here, Hippo. It seems to me that the patient died because of the burst liver. I really do think the water in the stomach is secondary. You may want to look over your data again.)

Interesting guy.

So I figure since “real” docs take the Hippocratic Oath, maybe I should read it. Good rule: Always start with the original text when doing research. Then, silly me and somewhat to be shock and awe, I wanted to find the modern version, and found instead a bunch of “modern” versions. I have three of them following the original.

Here is the original version (yes, translations differ, but that is your problem, not mine).

“I SWEAR by Apollo (wasn’t he a god or sumptin?) the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses (smile. Pagan!), that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents (mentor = daddy. Interesting concept. Sounds like a blood oath, Kemo Sabe.), to share my substance with him (are you selling Amway?), and relieve his necessities if required (mentor = sex daddy?); to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation (getting whored out just to learn a trade. Wow.); and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others (was there a secret handshake? I picture Fred Flintstone with his big blue hat while at the Loyal Order of Water Buffalos Lodge). I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous (OK). I will give no deadly medicine to any one if asked (OK), nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion (WHAT?!? You will NOT induce an abortion? Um, wait a minute … roughly 45MM abortions since 1972 in the US and the original text of the Oath includes a prohibition? Oh, it is to laugh.). With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work (Ewww! What pray tell is behind this crack? Cutting the tendons so they cannot escape?). Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males (and since docs were all guys, here’s a little gay reference.), of freemen and slaves (don’t go banging the patient – good rule). Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot! (whew, it ends like a spell. Eerie!)”

Well, old Hippo didn’t support abortion, did he? He’d get on all fours and let his teacher bang him doggy-style, but wouldn’t do his patients. Gotta draw lines somewhere, I guess. Interesting world.

Let’s see how the Oath was updated. Here’s the first modern version:

“I SWEAR in the presence of the Almighty (down to one god) and before my family, my teachers and my peers that according to my ability and judgment I will keep this Oath and Stipulation.

“TO RECKON all who have taught me this art equally dear to me as my parents (but you’re not going to sleep with them, right?) and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations (all?), so long as (funny, didn’t take long for the “but” to come in)the treatment of others is not compromised thereby (well, cowpoke, there is only so much of “you,” so in order to not compromise this fee-paying patient over here …), and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient (the origins of the referral system).

“I WILL FOLLOW that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous (tip of the hat to Hippo). I will neither prescribe nor administer a lethal dose of medicine to any patient (… any patient …) even if asked nor counsel any such thing nor perform the utmost respect for every human life from fertilization (oh my, methinks a prohibition against abortion has reared its head) to natural death and reject abortion that deliberately takes a unique human life (Oh! I should have read ahead, eh? “Reject abortion” coupled with previous reference of “life = fertilization” seems very clear. How interesting. I wonder how fully this position lies with Aristotle’s delayed ensoulment.).

“WITH PURITY, HOLINESS AND BENEFICENCE I will pass my life and practice my art. Except for the prudent correction of an imminent danger, I will neither treat any patient nor carry out any research on any human being without the valid informed consent of the subject or the appropriate legal protector thereof, understanding that research must have as its purpose the furtherance of the health of that individual. Into whatever patient setting I enter, I will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient. (There’s that “seduction” bit again! Must’ve been a real problem. Something just dawned on me – in all the usages, it is the doc seducing the patient. Always that form. So if she (or he!) starts it … weird demarcation. Why not just prohibit sexual relations with patients?)

“WHATEVER IN CONNECTION with my professional practice or not in connection with it I may see or hear in the lives of my patients which ought not be spoken abroad, I will not divulge, reckoning that all such should be kept secret.

“WHILE I CONTINUE to keep this Oath unviolated may it be granted to me to enjoy life and the practice of the art and science of medicine with the blessing of the Almighty and respected by my peers and society, but should I trespass and violate this Oath, may the reverse by my lot.”

Alright, substantially intact. Added a few bits about human research and informed consent. Good issues. Let’s see another “modern” version. Methinks the Indians are discussing leaving the reservation.

“I swear to (now down to zero gods) fulfill, to the best of my ability and judgment, this covenant:

“I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. (A little soft around the edges, but still very Fred-like.)

“I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. (But sometimes the exact appropriate amount of treatment is nihilistic. How do you handle that?)

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. (Oh man. How many docs do you know that skipped this paragraph?)

“I will not be ashamed to say "I know not," (ditto) nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery (share the wealth).

“I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life (in theory); this awesome responsibility must be faced (application) with great humbleness and awareness of my own frailty. Above all, I must not play at God. (Capital G? But you axed Him in the opening. Odd.)

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. (No comment.)

“I will prevent disease whenever I can, for prevention is preferable to cure.

“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

“If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”

That was an interesting shift in the treatment of abortion – from clear to cryptic. Still present, in some carnival mirror sort of way. Notice what is missing entirely? Docs can now nail their patients – male and female – regardless of who initiates it!

Last and, yes, least I found the AMA approved version. The reservation is now devoid of human inhabitants.

“You do solemnly swear, each by whatever he or she holds most sacred (Hunh? “whatever”? Good lord, talk about politically correct): That you will be loyal to the Profession of Medicine and just and generous (read, “make referrals early and often”) to its members. That you will lead your lives and practice your art in uprightness and honor.

“That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice. (Is this code for boning patients?)

“That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it. (Cure = good; criminal = bad. Silent on preventing abortion. Silent on assisted suicide. But neither “cure” do they?)

“That whatsoever you shall see or hear of the lives of men or women which is not fitting to be spoken, you will keep inviolably secret.

“These things do you swear. Let each bow the head in sign of acquiescence. And now, if you will be true to this, your oath, may prosperity and good repute be ever yours; the opposite, if you shall prove yourselves forsworn.”

The AMA sucks. Remarkable how much they changed from Hippo’s first writing. Why do they even continue to use the name?

rectally speaking

You people think I am exaggerating when I tell you that docs have a butt-insertion fetish. Well, to wit:

“A 60-year-old man with acute pancreatitis developed persistent hiccups after insertion of a nasogastric tube. Removal of the latter did not terminate the hiccups which had also been treated with different drugs, and several manoeuvres were attempted, but with no success. Digital rectal massage was then performed resulting in abrupt cessation of the hiccups. Recurrence of the hiccups occurred several hours later, and again, they were terminated immediately with digital rectal massage. No other recurrences were observed. This is the second reported case associating cessation of intractable hiccups with digital rectal massage. We suggest that this manoeuvre should be considered in cases of intractable hiccups before proceeding with pharmacological agents.”

Now, the guy’s got hiccups. That’s a mouth thing, right? I mean, out the other end, he would be a serial farter. No, it’s his mouth. He won’t stop. What to do? Well, stick your fingers up his ass. Makes sense, eh? Can’t you picture it? Hiccup, hiccup, hiccup, insert, silence, extract, hiccup, hiccup, insert, silence, extract, hiccup …

“Dr. Bob, I think we have something here!”

“Yes, Dr. Jim, I agree. What a novel idea! Tell me, how did you conceptualize of this solution?”

“Well, Dr. Bob, I was reading one of my old Med School textbooks, How and When to Compromise the Anal Cavity. Just for old times’ sake, really. Loved that course. And I noticed that I jotted in the margin, ‘Always,’ and ‘At every opportunity.’ Then later in the book, I found a muse I wrote to myself, ‘The butthole is the gateway to health.’ I started thinking. Remember Extant Physiology Lab, where we tried to push the existing knowledge of biological functions?”

“Yes, Dr. Jim, I do.”

“Well, Dr. Bob, at NYU we tested the hypothesis that a person could not burp and fart at the same time. We were amazed that the historical data was so conclusive. So we began controlled tests among volunteers from the general population, and then later amongst ourselves.”

“Go on, Dr. Jim”

“Alright, Dr. Bob. From a scientific viewpoint, it has to be understood that a ‘fart’ is not something defined purely by auditory cognition.”

“Of course, Dr. Jim.”

“Yes. It is the mere passing of gaseous fecal matter that establishes whether or not a ‘fart’ has occurred.”

“The silent-but-deadly effect.”

“Precisely! So we rigged a sensor line into a Dixie cup and duct taped the device onto the posterior out-door.”

“Brilliant!”

“Thank you, Dr. Bob.”

“You are welcome, Dr. Jim. We then induced a burp effect through the consumption of various soft drinks.”

“Did you also enhance the physiological environment to increase the likelihood of farting?”

“You are following this research closely. I am impressed, Dr. Jim.”

“As am I with myself, Dr. Bob.”

“As well you should be, Dr. Jim. As you anticipated, the original experiment design was fatally flawed. The subjects burped on a recurring and frequent basis, but watch as we did – no farts.”

“What did you do in response, Dr. Bob?”

“We adjusted the testing protocol, after appropriate presentation and approval from the Chief of the Medical Staff, to isolate a subject-preparation phase.”

“Do tell.”

“Before a subject was fitted with the butt-gas capture system, we sat them in a room for thirty minutes and feed them beans and Coke.”

“Brilliant!”

“Thank you, Dr. Jim. We anxiously watched both mouths and butts of the subjects. It usually took no more than 15 minutes post-consumption for the body to respond.”

“And what were the observations, Dr. Bob?”

“The subjects did indeed burp and fart rather intensely, however, never at the same time!”

“Fascinating!”

“Yes. Now we had to figure out why.”

“And did you?”

“No. Funding ran out. But this one subject had such a magnificent ass that I chose to specialize in gynecology.”

“So the research was a success.”

“Yes, it was.”

“So tell me, Dr. Bob, how does that research relate to the patient in front of us now, the one with repeating hiccups?”

“Simple, Dr. Jim, and forgive me for suggesting that I am rather shocked that you do not see the correlation already.”

“I am merely deferring to your expertise, Dr. Bob, and I hope to hear more about the specialty-inducing subject as well.”

“Very well, Dr. Jim. The results of my previous research as applied to the present situation are thus: If one cannot fart and burp at the same time, then there must be a relationship between the two escape hatches. It cannot be avoided. So, if a patient presents with hyper-activity in one of the regions, compromise the other and see what happens!”

“Research in action!”

“Yes!”

“So, tell me, have you ever treated a serial farter by cramming something down their throat?”

“Yes, but the hospital’s legal staff informs me that I cannot speak of the matter until the litigation is resolved.”

“I understand.”

I get hiccups upon occasion. I wonder if my insurance company will pay for a butt plug? “Hello, Blue Cross Nurse Hotline? Can’t stop my hiccups. Any ideas? Hmmm. Didn’t think of that … ok … hhmmmm … alright. And that’s covered? Wow. Ok. Thank you. Have a nice day.”

Hiccup. Insert. Silence. Ut oh! My pants are getting tight!

the doctor is in 6

It’s good to get back into the cyber-office after the Holidays. Trust yours was enjoyable and nobody got hurt too badly – remember, it’s all fun and games until the cops show up.

Today’s case is called, “Swelling and Pain in the Back and Hip of a 35-Year-Old Man.”

Let’s start out with an exterior shot.


Dang! That boy got some butt. No hair, cute little cheeks. Ut oh! What’s that up the top of the ole crack in the china? A little protruding buddy, eh, son? Sensitive to touch? Bet you have to hang up the thongs for a bit.

We need a better look. Have to go inside. No, not the anal-intrusion instrument – I am an internet doc; only “real” docs invade the chubster on any excuse. We’re gonna use one of those machines with letters for a name, whichever one is available. “Hey, tell the tech, top down, 32 degree lateral shots from points A to B, C to F, and X to A1.” I have no idea what that means, but everything I say they write down and these picture thingeys come back, so it must be something.

Let’s see what they found …


YOWO! Lookey here! The boy’s got an ALIEN in his BUTT! AN ALIEN!! This is so cool! It’s got floppy ears! The protrusion out of his butt is its HEAD! It must have parked itself there for the food supply. Smart, them aliens are. Got a bunch of fat to suckle and, of course, the ultimate food supply – the colon – food’s already digested, got that dark chocolate nutty flavor. This is a first in the annals of medical science! A documented alien in the butt!

Another pic? What’s this?


Oh, no! This guy is in trouble. See those two circles? Alien eggs embedded in his butt cheeks. Toast. Better schedule an untimely death and burn this dude’s carcass. He’s got one alien already hatched, ears fully deployed, and two more coming. Them butt cheeks ain’t gonna be so cute in another few weeks. I estimate about 4 to 6 weeks max gestation left. I wonder if we can toss him into coma somehow, then fix the records to show his brain waves isoelectric. That hatched alien decides to exit, it’ll get ugly! They sneak right out the butt when you are aren’t looking! Let’s hope it’s a mama alien and will stay put until the eggs hatch. Man, this is so sad.

Let’s hear the guy’s story …

BACKGROUND. A 35-year-old man presents to the emergency department (ED) complaining of sacral pain and right hip pain (damn straight. Hatched aliens HURT!). The pain is associated with increasing swelling in these regions that began 3 days before presentation (the little alien dude hatched just a little time ago. That’s good news, actually. Not likely to venture out soon.). The patient otherwise denies having any systemic symptoms, such as fevers, chills, nausea, or vomiting (I agree. Aliens don’t like it warm. Anyway, they eat vomit like ice cream before it ever gets a chance to leave). His past medical history is significant for a recent admission to the hospital after an accident with a motor vehicle approximately 2 weeks before presentation (I don’t like the sounds of this). As a pedestrian, the patient was struck by a car and sustained multiple rib fractures and facial lacerations (an alien hit-and-run. Typical. Once he was dazed, this stick the eggs in his butt. Notice the precision with which they placed the eggs – right cheek, left cheek, top of the crack. Very common in alien-egg insertions. This poor guy.). He was discharged to home from the hospital 10 days before presentation and has been doing relatively well, with adequate pain control for his rib fractures.

On physical examination, the patient’s temperature is 98.96°F(37.20°C) (I can tell you right now that everything is normal – aliens cover their tracks well. We’re lucky to have found these), with a blood pressure of 129/67 mm Hg and a heart rate of 89 bpm. His respiratory rate is 20 breaths/min, and his O2 saturation is 95% while breathing room air. The patient is not in acute distress. The head, eyes, ears, nose, and throat (HEENT) examination shows well-healing facial lacerations with intact sutures. His chest is clear to auscultation on both sides, with normal cardiovascular and abdominal findings. The lower extremities have normal sensation and 5/5 strength (on a scale of 0-5, with 0 being no strength and 5 being normal strength) (see? Normal across the board. Aliens in the butt. Man, I hate aliens).

A visible fluid collection is observed in the proximal lateral aspect of his right thigh (aliens gotta pee, too; it’s building up in his legs. We gotta act fast.). The fluid seems to track up (track UP? Idiots. It is flowing DOWN. Alien pee) around the gluteus maximus muscle to the lumbosacral region, with slight crossing of the midline to the left. The fluid appears to be a free-flowing, low-viscosity collection without evidence of erythema or ecchymosis (that is EXACTLY how alien pee presents). No loculation is noted on palpation, and the patient has no thickening or induration of the skin in the overlying and surrounding areas (all normal … see what I told you?).

What is the diagnosis? (One hatched alien distal to the butt crack; two alien eggs embedded one in each of his butt cheeks; accumulation of alien pee in his legs – simple – we’re done here!)

HINT. This fluid collection was not appreciated during the patient’s previous admission to the hospital. (Of course it wasn’t! The dang thing just hatched! What kind of hint was that? Ah, I get it! See, they are telling you they KNOW it is a recently hatched alien! A-HA!)

ANSWER. Closed, internal degloving injury (“degloving” is code for floppy-eared alien): The patient underwent computed tomography (CT) scanning of the pelvis, which showed a large, subcutaneous fluid collection extending from the region of the lumbosacral spine along the right lateral buttock to the thigh and down to the level of the femoral shaft (alien; pee). The fluid collection was not present on a previous CT scan that was obtained 2 weeks before presentation (the time of the motor vehicle collision) (you mean, before they implanted their eggs INTO him? Of course not!). The patient’s laboratory studies showed a white blood cell (WBC) count of 8.38 × 109/L; hematocrit, 0.363 (36.3%); platelet count, 953 × 109/L (953 × 103/µL); and an international normalized ratio (INR) of 1.0 (yep, yep, yep, yep – alien, alien, alien, alien. Wait until the pee starts to accumulate – that’ll crank his white count!).

The patient underwent CT-guided aspiration of the fluid collection under local anesthesia. An 8F catheter was used to aspirate 800 mL of dark red fluid (alien blood – careful, they bite!). Postaspiration CT images demonstrated near-complete resolution of the fluid collection (yeah, do you think they are stupid? It went to lunch! Just parked itself INSIDE the colon for a spell), and the catheter was removed (and the alien came back). A pressure dressing (elastic spica dressing) was applied. An elastic bandage was wrapped around the entire thigh, beginning just proximal to the knee, and continued upward across the proximal thigh and buttock. The bandage was wrapped around the waist several times and then brought back over the thigh to compress the entire lower back, buttock, and proximal thigh. The patient tolerated the procedure well and was discharged to home the following day. He was instructed to wear the compression dressing as much as possible, and a follow-up visit was scheduled. The aspirated fluid was sent for bacterial culture and found to be negative for bacteria (aliens don’t have Earth bacteria! Bet you didn’t scan for non-Earth bacteria, did you?).

(I can’t listen to these idiots anymore. Aspirate, my ass! This dude has a serious alien infestation. Let’s put him under, flat-line his results, fake an autopsy, and burn him. These things lay eggs like turtles – all plop, plop, plop until the hole is filled – and the hole, in this instance, is his two butt cheeks! I’m outta here – office closed!)

A closed, internal degloving injury is a clinically significant soft-tissue injury that is associated with pelvic trauma. The subcutaneous tissue is torn away from the underlying fascia, which creates a potential space that can fill with serous fluid and/or a hematoma caused by the disruption of the arteries that perforate through the fascia mixed with viable and necrotic fat. The condition commonly occurs over the greater trochanter, but it can occur anywhere over the trunk, buttock, or thighs. When a closed, internal degloving injury occurs over the greater trochanter, the condition is known as a Morel-Lavallee lesion. As mentioned, this condition usually occurs in association with pelvic and acetabular fractures, but it can also occur in the absence of fractures. Direct crush injury to the pelvis or a high-speed motor vehicle crash are the most common mechanisms of injury. The importance of this soft-tissue injury may not be initially apparent; some patients present months after the initial event, complaining of soft-tissue swelling or contour abnormalities that are not resolving.

The diagnosis of a closed, internal degloving injury is usually based on physical findings (ie, a soft, fluctuant area over the lesion and a loss of local sensation). Diagnostic aids may include ultrasonography and CT imaging. Various methods or combinations of techniques for treating degloved areas have been suggested, including the application of compression dressings, fluid aspiration or liposuction, injection of sclerosing agents, deep fascial fenestration, prolonged closed surgical drainage, and open surgical debridement (ie, leaving the degloved area open for closure by secondary intention). A review of the available literature, while failing to reveal prospective comparisons, did demonstrate variable outcomes with different therapeutic approaches, ranging from complete resolution to the development of various complications, including infections and skin necrosis or breakdown. The complications associated with closed, internal degloving injuries often require extensive therapy and surgical management.

the doctor is in 5

just learned something about odiogo audio - i need to use different titles. it associated this post with an older one. so i am deleting and reposting. will use doctor is in 5 ... then 6 ...

Today we are presented with a 68 year-old. We’ll get to his story in a few. First, the pics …


Oh my! Looks like the dude swallowed somebody’s scrotum! That’s gross. I mean, nuts still wrapped up like a couple mini-pillows just-for-to-sleep-on-honey-oh-no-thank-you! seem to be lodged in this guy’s throat. Wanna have some fun? Take your browser slider and move it up and down a bit – the old chin strap seems to move around as if it were riding free in a pair of Levi’s and we are frolicking in a meadow feeling free and pretty like those girls that wear panti-liners. Hey, wait a sec … look at that kinda sorta line of white under the scrotal package. Odd. Wonder what it is. Better look at the next pic.


AAHH!! AAAHHHH!!!! AAHHH!!! NO!!! SAY IT ISN’T SO!!! AAAHHHHH!!!! IT IS!!! The dude SWALLOWED somebody’s DICK!! AHHH!! AAAAHHHHH!!! NNOOOOO!!!!! AND IT WAS STILL PUMPING THE LOVE JUICE!!! IT’S RIGHT THERE! LJ’S STILL DRIPPING!! IT’S IN HIM. NOO!!! AAAHHHH!!!!!

This boy better have a good story. Ain’t never no reason no-how to go chomping down on the spanker, and in particular … AAHH!! AAAHHHH!!!! THE DUDE HAD HIS LOVE PUMP LOVING IN SOME OTHER DUDE’S MOUTH AND GOT BIT BIG TIME! AAHH!! AAAHHHH!!!! And then this low-down geriatric sexual purveyor of “Dick: The Other White Meat” couldn’t stop there – he had to take the lil buddies, too? Damn, man, what is you thinking?

You better have a DAMN fine story, or I am going toss HIPAA right out that window, track down your sorry ass, and perform a stomach stapling without anesthesia. You won’t eat another thing, son, for the rest of your days. You done had your last meal!

Alright – cough, I want the story. I’m listening.

BACKGROUND

A 68-year-old (sixty-eight, 68! You should know better, son! Ain’t your dick still attached? You like it there? You tinkle on a regular basis? What is wrong with you?), previously healthy white man (I knew he was white, just by viewing the crime scene – I knew it. Yeah, “previously healthy” until you started chomping. I oughta kick your ass right through this cyber-diagnosis) presents to his primary care physician’s office with a complaint of 2 years of progressive dysphagia (Two years, my ass! That dick still dripping momma’s milk! You lie so bad). He reports that he has lost about 15-20 lb and that he is not following any diet or regimen to lose weight (unsafe sexual practices can lead to weight lose, too, grampaw. I don’t see no rubber on that rascal. You surfing bareback. Why you surprised you losing weight? Probably fit into a size 9 cocktail dress now, don’t you?). Although he can drink liquids without difficulty, he has lately felt a “sticky sensation” in the middle of his throat (it’s still dripping – can’t you people see that? Of course it’s sticky! It’s gots to stick to the egg – it’s designed that way! HEY – THE DUDE BIT OFF AND SWALLOWED SOMEBODY’S DICK THEN WENT AFTER THE MUD FLAP! YEAH – STICKY – SURPRISED? You want to know what is even more sticky? When the now-flapless-and-dickless partner goes home to his WIFE and has to EXPLAIN where his DICK went – and STILL is!) when he eats any solid food (I think our friend has had enough solid food for one lifetime). He also regurgitates food particles from a particular meal for up to 2 days after he has eaten it (I am positive this is true. Yes, whatever he eats comes back up. Yes. I have no problem believing this).

On physical examination, the patient’s vital signs are within the normal range. The examination of the oropharynx yields unremarkable findings. The patient has no neck mass or other abnormality. Examination of the thorax and the abdomen also yield unremarkable results. (Blah, blah blah. The formerly attached dick lost its erection. You would, too, with a good bite-down. So of course you don’t feel anything in there. It’s sticky – but soft.)

HINT
Observe the saclike structure in the esophagus. (Scrotal fun buns, dick. Saw them. Thanks.)

ANSWER
Zenker (so that’s his name. Better write that down. I can find him. No problem. I’ll do the Whistle Test. Little known fact: Dicks lodged in throats prevent whistling. Something about the way air moves in the diaphragm. I’ll find every 68 year-old Zenker in America and make them whistle. When one can’t – I’ll have my man!) (pharyngoesophageal) diverticulum: The frontal (see Image 1) and lateral (see Image 2) barium-swallow images of the upper esophagus demonstrate a large outpouching (what a great medical term, “outpouching.” I prefer “lodged spanker.”) at the posterior aspect of the pharyngoesophageal junction that retains barium (arrows) (I think “barium” is code for “seminal fluid”). This finding is consistent with a Zenker diverticulum (Latin for “pervert.” Zenker, Pervert. Now I have a complete name. This dude is so toast).

A Zenker diverticulum, also called a pharyngoesophageal diverticulum, is a pseudodiverticulum (note, “pseudo” – this answer is full of code only us internet docs can read) consisting of esophageal mucosa and submucosa (read, “seminal fluid”) that herniate (“the buddies”) posteriorly between the cricopharyngeus and the inferior pharyngeal constrictor muscles (like a pirate map to show you where to find your nuts if your wife said, “go back and get them! And don’t return until you do!”) and through an area of potential weakness referred to as the Killian dehiscence (the first clue as to the victim’s identity – a Mr. Killian). The pathogenesis of this condition is not well known (this means that they don’t have much information on Mr. Killian – must have been a chance encounter in a bar, mayeb a glory hole). Patients with a Zenker diverticulum are thought to have a discoordination of the swallowing mechanism that increases pressure on the mucosa of the pharynx (this “discoordination” means that he didn’t want to bite the guy’s dick off – but got the “mucosa” thing happening, which means he did bite the guy’s dick off). Over time, this pressure leads to herniation of the esophageal mucosa through the Killian dehiscence (“Over time … herniation” – Mr. P. Zenker bite off the dick of one Mr. Killian, and then bit off and removed the remainder of the male package).

The condition occurs most commonly in elderly women (this should come as no surprise), with peak incidence in the seventh to ninth decades of life (OK, good information. No wonder older men tend to be so quiet – fear of being Zenkered). The most common presenting feature in a Zenker diverticulum is upper-esophageal dysphagia, which occurs in as many as 98% of patients (this means that the dick get lodged pretty high up). Other common symptoms are halitosis (you’ve got a dick in your throat, probably been there for days – of course your breath stinks), regurgitation of undigested food, aspiration, noisy deglutition, and changes in voice (eg, hoarseness) (yeah, what about the change in voice in the bitee?). Weight loss, possibly resulting from limited caloric intake (tough to get calories around that thing in your throat, eh, grammaw?) and recurrent pulmonary infection from aspiration, occurs in approximately one third of patients.

(Blah, blah, blah. Read the rest of the pseudo-answer if you like. Here’s the bottom line. Diagnosis: Dick and Scotty lodged in throat. Recommended treatment: Shoot him right between the legs, then between the eyes. Put his crime on prune juice containers for all prospective criminals to see – face, facts, final disposition – under the caption, “Don’t be a Zenker!”)

In patients with a Zenker diverticulum, the physical findings are usually normal. Fluoroscopic barium-swallow studies are the mainstay of diagnosis and demonstrate the characteristic outpouching that arises from the midline of the posterior wall of the distal pharynx near the pharyngoesophageal junction. This finding is best identified during swallowing, and it is typically seen on lateral images, on which the diverticulum is observed at the C5-C6 vertebral level. If the diverticulum is large, it may protrude laterally, most often to the left side. After the bolus of contrast agent passes the upper esophagus, the diverticulum is typically seen extending posterior to the cricopharyngeus muscle, and the contrast material that was retained in the diverticulum may be regurgitated into the hypopharynx. The lumen of the diverticulum should be carefully observed for irregularities or filling defects because squamous cell carcinoma can develop in a small percentage of cases.

When incidentally imaged on computed tomography (CT) scans or magnetic resonance imaging (MRI) scans, a Zenker diverticulum appears as a structure that arises posteriorly from the hypopharynx and is filled with air, fluid, or oral contrast material. Zenker diverticula may also be found on endoscopy. Care must be taken during endoscopic procedures, because passage of the endoscope into the diverticulum may result in perforation.

Small, asymptomatic diverticula may be followed up by monitoring the progression of symptoms. Surgical management should be considered in patients with clinically significant dysphagia, weight loss, pulmonary aspiration with recurrent lung infections, and complications related to bleeding. Surgical options for treatment include myotomy of the cricopharyngeus muscle, with or without diverticulopexy, and endoscopic division of diverticular wall with stapling. The success rate (ie, the relief of symptoms as measured in most studies) is approximately 93%.

rambling rose

I really like being a doctor, but in a lot of ways it makes me feel dirty, so I am going to take come time off from the practice. Why does it make me feel dirty? Well, first it just does. All that pus and oozing and white trash with mouth sores, but beyond the tossing and turning to nightmares about talking to these people in a small room and smelling them, it came home to me this morning when I checked my site meter. Somebody from Madrid searched “anal” and got me. They didn’t just “get me” – I got the number one spot. Just, yuk. I figure if I leave the incoming case studies as unread e’s, it’ll be like cryogenic storage or something and nobody will die. They can talk to Uncle Walt’s head over there in Vault MM. I do have that “alien in the butt” case to resolve, though. I already opened that e, so it’ll be like two-week expired tofu in another couple of days.

I read on some blog that Paris says that she that is going to be cryo’d so that she can come back to blow some future guy in whatever passes for the front seat of a car. I think someone needs to tell her that people have, like, looked into the future and, like, everything gets cured but face lines and age spots. I mean, like, everything! No more big butts, that c-word … censored … no … commercial … no … ca-ca-canber – cancer! That’s it. That gets cured, too. But, like, it’s really bad because everybody gets cured of all these horrible diseases and, like, conditions but all that means is that they live to be old people. And, like, since face lines and spots couldn’t be cured, the old people look like old people. So what happens is that, like, beautiful people, like Paris is right now – just so awesome, pristine, like a Greek goddess – are, like, these big prizes. They get stuff all the time. People just love them. It’s like everybody is an illegal working for granddaddy’s hotels or something. So, like, my point is that if she waits, if Paris waits to get cyro’d and she’s got these lines and spots, too, then she’ll wake up as the hotel staff, and the only blowjobs she’ll be giving will be to other hotel staff in, like, hotel rooms that somebody else slept in the night before. That can’t happen! Not to Paris! Somebody needs to tell her. She has to cyro right now while she is still so beautiful and pretty. And what would be really fun, and somebody needs to tell her this, too, is that she should get all of her best friends cryo’d at the same time. They could wake up, like, a billion years from now, and start out a new life with the coke she stashed in her jeans, and then she could take her friend’s hand and go find a car. Somebody please tell her! Please!

I’ve mentioned it before, but I enjoy reading the posts on totally unauthorized. I wish she would add me to her blogroll – I mean, like, have I got to beg? I am not beneath that by any measure, but it would be nice to be asked to grovel. btw, I like to be kicked but not spit at. Spitting is gross, generally. Well … OK, I better stop.

I play houseboy today. Laundry, dishes, maybe I can get one of the minions to vacuum. My daughter is real good about helping. Does it without being asked. Penn State plays Ohio State tonight. All the ESPN guys say Ohio State will trample them. It is to laugh. Or cry. It’s OK, though, I have alcohol somewhere.

I detest the news in any form. The TV is never on when I am alone in the room. I stay away from news sites. Here’s another example of why: Apple is stupid. Always was. It sat back and held its source code from developers while Microsoft did the exact opposite. The result was an industry replete with Microsoft applications, and cute little programs for Apple. Apple can be innovative, but so can an idiot savant locked in a padded room. So here is Apple saying no cash and limit of two iPhones to deter resellers. Deter? I got the phone in my hands. I am going to resell it. Doesn’t matter to me if it is on a card or with cash. So I leave the money in the bank and give you a debit card. WTF? How does your system deter resellers? Unless, of course, this is an illegal alien thing. The market where people are hacking iPhones and reselling them is not concentrated in the illegal alien population. Dumb. And look here to see the future: Nextel is unlocking its phones. It’s another losing battle, Apple, of which you find yourself on the wrong end (again). Got a product? Sell it for more than it cost you to bring to market. End of story. Stop the social engineering. You suck at it.

It has been raining for a few days. Reminds me of living in California, but without the illegals on every street corner hawking hacked iPhones. Supposed to stop raining around 11:00AM. Whatever.

I like rain. Closes me in. I am a quiet person when I’m alone, and I am alone often. I used to flip whenever I was in the company of anyone so that they could be entertained. I broke that habit over the past couple of years. So I am much more quiet all the time, except for work things. They expect vibrancy, so I fulfill their expectations. The majority of my work, however, is at home. I get my phone calls, my dozen or two of e’s each day, but the majority of what I do is creating words and data. I hope this phase doesn’t end soon. I like being alone. I rarely go out of the house. I drove to the store two days ago, I think it was. Few groceries. I never go to restaurants anymore except when I am on the road. Quiet times for me. I like it. A lot.

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.

the doctor is in

OH YEAH, BABY! The doctor be IN! No intro. Straight to the pic – this just came in moments ago. Here you go:

(Hand raised – bouncing in seat.) Pick me! PICK ME! I got it! I KNOW THIS ONE! Know that with no more data! This boy done got the scratch! He been doin’ some ho’s and shit! Been banging and shit with the nasty girls! See where that is, way up along the top part? WTF wrong with this man? He ain’t using no rubber! He be just banging and banging and banging! Dumb motherf—ker. Serve him right. I hope his dick falls off. Stupid motherf—ker out there making it nasty for the rest of us.

Let’s see what this man has to say for himself …

BACKGROUND. (“Background” shit – this man doing ho’s with no rubber. Get the f-ck outta here. Alright, alright. I’ll shut up. Let the man say his piece, lying motherf—ker.) A 52-year-old man (52! You should know better, stupid motherf—ker. Where you head at, besides buried in some ho’s twat?) with no clinically significant medical history presents to the emergency department with a chief complaint of a “rash” on his penis (A rash? A RASH?!? You dumb motherf—ker, that be the scratch and you know it! You trying to get free medical or sumptin? F—cking lying piece of sh—t you be.). The patient states that the rash first appeared 1 week before presentation. He denies any dysuria, urethral discharge, pruritus or pain in the area of the lesion. This is the first time he has had such a rash (lying piece of shit, you be lying like a motherf—king rug). He admits to having had several recent sexual partners(ho,ho,ho, motherf—ker wit no rubber).

On physical examination, his vital signs are normal (you check for a brain?). The patient has a well-demarcated, ulcerated lesion (always is) on the ventral aspect of his penis (see Image). The lesion is not tender to palpation (never is). No other lesions are noted (better hope not, mofo, else that dick be falling off!), and no discharge is observed from the urethra (just wait.). The findings of his testicular examination are unremarkable (“Hey baby, whachu doin after work? Maybe you and me go steppin’ out. I gots some blow with your name on it.” "Not with that dick you ain't steppin' out wit nobody like me."), with the exception of bilateral prominent inguinal lymphadenopathy (that means sumptin be big down there that ain’t aposta be big, like Swollen Nut Syndrome. This stupid motherf—ker be sick!). The remaining physical findings, including the cardiac and abdominal findings, are unremarkable.

What is the diagnosis, and what empiric treatment is necessary? (The boy gots the scratch. Give him some penicillin and a handful of rubbers. Better check him for The Drip and Crabs. I hopes he’s gots them all. Serve him right. Dumb motherf—ker.)

(I’ll just let the answer run. I don’t care nuttin for this jackass.)

ANSWER. Primary syphilis: Syphilis, an infectious disease caused by the spirochete Treponema pallidum, is usually transmitted by means of sexual contact; the usual route of transmission is the skin or mucous membranes of an uninfected sexual partner coming in contact with the mucosal ulcerations (eg, in the genital area, mouth, or anus) of an infected partner.

In the United States, the rate of primary and secondary syphilis declined by 89% from 1990 to 2000; however, in November 2005, the Centers for Disease Control and Prevention (CDC) reported that the number of primary and secondary cases of syphilis had been increasing, from 2.6 cases per 100,000 population in 2002 to 4.7 cases per 100,000 population in 2004 (an increase of 87%). This rise was partially attributed to increased rates of infection among men who have sex with men, who in 2004 represented 64% (up from 5% in 1999) of all cases of primary and secondary syphilis in the United States.2

Primary syphilis manifests as a nonpainful ulcer (chancre) at the site of infection. The lesion is usually on the genital area, but it may also occur on the lips, tongue, cervix, or anus of the infected person. This lesion usually develops within 3-4 weeks after infection, but it may occur as long as 3 months after. The primary lesion spontaneously heals in 3-7 weeks, and it may go unnoticed, especially if it is on the cervix or anus; therefore, infected individuals may not realize that they have an infection. Unilateral or bilateral regional painless lymphadenopathy is also a characteristic finding of primary syphilis.

Secondary syphilis is the next phase of the disease, developing 4-10 weeks after the primary lesion appears. This phase is marked by nonspecific systemic complaints, such as fever, headache, fatigue, and lymphadenopathy. A characteristic rash that consists of round, discrete, nonpruritic macules on the trunk and proximal extremities and penny-sized, reddish-brown sores, appears on the palms, soles, scalp, and face in this phase. These sores may coalesce to form highly infectious lesions called condylomata lata. Symptomatic secondary syphilis also spontaneously resolves, and the disease then enters a latent period where few if any symptoms are seen; the latent phase is divided into “early” and “late” periods. Symptoms may recur in the early latent stage (during the first 2 years of infection). The disease then goes into the late latent phase, when patients remain asymptomatic and noninfectious.

About one third of patients with primary syphilis develop a form of the disease called tertiary syphilis, which is a chronic inflammatory process that progresses over years and decades and results in varied symptoms and physical findings, including mental illness, blindness, heart problems, and eventual death. Cardiovascular syphilis can cause devastating damage to the heart, including aortic endarteritis with medial necrosis and aneurysm formation. Gummatous syphilis manifests as coalescent granulomatous lesions affecting the bones, joints, skin, or almost any part of the body. Finally, symptomatic neurosyphilis can lead to meningitis, brain parenchymal infection, endarteritis, or stroke.

Standard treatment for primary syphilis or for syphilitic infection <1 year after exposure is benzathine penicillin G 2.4 million U given by intramuscular (IM) injection. Alternate regimens for patients allergic to penicillin are a 2-week course of doxycycline 100 mg given orally (PO) twice daily (BID) for 14 days, tetracycline 500 mg PO 4 times daily (QID) for 14 days, or ceftriaxone 1 g given IM or intravenously (IV) once a day for 8-10 days. A recent study also demonstrated efficacy with azithromycin 2 g PO as a single dose; however, the authors suggested caution in applying this finding to patients in the United States, because the trial was conducted in a geographically limited area outside of the US, and because macrolide resistance has already been demonstrated in the US.1

If the patient was infected for >1 year at the time of presentation, benzathine penicillin G (2.4 million U IM once a week for 3 consecutive weeks), or doxycycline for 4 weeks is recommended. Neurosyphilis requires treatment with aqueous crystalline penicillin G 2-4 million U IV every 4 hours for 10-14 days. Patients with neurosyphilis should also be followed up every 6 months for 3-4 years for cerebrospinal fluid (CSF) and serologic testing.

Given this patient’s allergy to penicillin and current social situation, he was treated with azithromycin 2 g PO instead of a 14-day course of doxycycline. The ulcerative lesion was swabbed and sent for darkfield microscopy. Rapid plasma reagin (RPR) and Venereal Disease Research Laboratories (VDRL) serum studies were also ordered. A urine sample was sent for Neisseria gonorrhoeae and Chlamydia polymerase chain reaction (PCR), and the patient was counseled about concomitant sexually transmitted diseases (STDs), including HIV. He was referred for HIV testing and given a fast-track follow-up appointment for the laboratory results.