Doctor Plays Doctordle but the Video Ends When He Gets 1 Wrong

[00:00:00]Today I present to you doing as many doctoral questions as I can in one stream until I get one wrong. A 24 yearear-old female patient presents to the ED with severe epigastric abdominal pain for the last 24 hours. So for the last 24 hours means that this is a pretty acute thing. Epigastric means that you're more like in the upper stomach area um centered around kind of like the middle lower part of the chest.

[00:00:28]Um, so definitely not really area for appendix, not really the area for like ovarian cyst. Um, epigastric abdominal pain. So this this could again it can literally be anything in before something wild like Mallalerie Weiss tear. No, no, you can you can you can literally go ahead. Mallerie Weiss syndrome, right? I mean, it's it's it's Dr. Dole. We'll we'll eventually get it in six, right? like there there's no there's no shame in getting it wrong after the first or second one, right?

[00:00:59]So, she reports that she recently started a new birth control and weight loss regimen. Uh, okay. So, now we're worried about kind of like drug induced reactions or weight loss regimen is another one too. So I guess with weight loss I mean this this is just super out there but weight loss you're also thinking of things like um like meantic eskeeia there's there is a thing where uh patients lose the abdominal fat pad um that's basically holding up the superior mesenteric artery and once you lose that fat pad you can get eskeeia because your blood flow through that artery is impacted because the angle is too shallow. I I don't know. [laughter] I don't even know. I don't even know where to start with. So, birth control and weight loss regimen. I'm kind of I'm kind of thinking like drug drug reactions, right? I mean, new birth control. New birth control with new epigastric abdominal pain for the last 24 hours. Pancreas, right? Yeah, it could be. Um, birth control falls under I guess it would fall under like the drugs section, right? So [laughter] um the the full pneummonic for all the different causes of acute pancreatitis is I get PP smashed right so it's it's idiopathic it's gallstones it's ethanol it's uh trauma it's P being pancreas devisesum which is very stupid uh the other P is going to be posterior dadinal ulcer uh [laughter] PP smashed you're also going going to have like scorpion sting, but the scorpion like only lives in like Trinidad or something. Uh M is Oh crap. What's M? Oh yeah, MS, right?

[00:02:51][laughter] That's how you know that I I'm an internal medicine doctor because I just like never encounter that. [laughter] It's idiopathic, then gallstones, ethanol trauma, posterior dadinal ulcer, pancreatitis to whisum. Um S is steroids, M is mumps, A is autoimmune, S is the spiderbite/ scorpion stings, which I already talked about. H is hyper triglyceridemia. Uh E is ERCP induced, which is like we do a procedure to take a look and that injures the pancreas.

[00:03:25]And then D is drugs. So all of this is to say acute pancreatitis totally is in the differential. [laughter] Honestly, pancreatitis could be a good one.

[00:03:37]Eh, patient is tachocartic and hypertensive. Lab testing reveals mild hyponetriia. I'm thinking like a like a thyroid picture. I mean, there are very few things that make you tacky and hypertensive. Like, I'm thinking thyroid, maybe renal. Lab testing reveals mild hyponetriia. So, I guess it's pointing more toward towards renal.

[00:04:01]Um, but why would renal lead to epigastric abdominal pain? That's hm.

[00:04:06]Okay. Uh, pain. Try like the sixth clue is going to be like patient also just got into a car accident. Actually, you know what? Scaroderma renal cra doesn't have it. Uh, this tacky hypertensive thing is throwing. So, it's like I'm thinking thyroid, but also hyponetriia kind of points more towards kidney, but epigastric abdominal pain doesn't really cover thyroid or kidney. So, I'm not I'm not really sure. Acute intermittent pferia because it's lasts 24 hours actually. I mean, I I guess I guess pferia kind of fits because it's like a drug induced reaction from probably her new birth control. Ah, she has a clot from the OCP causing bowel eskemia.

[00:04:49]That's why I wanted to put SMA syndrome.

[00:04:51]Like she has uh she has like a thrombosis and it's causing meantic eskemia. Um should I put AIP? Oh my god.

[00:05:00]Acute intermittent pferia. Like it's not wrong. How the did you get that? Wait.

[00:05:06]Okay. Okay. Okay. Okay. So, [laughter] while in the ED, the patient begins to exhibit paranoid delusions and agitation requiring mild sedation. Further questioning of the family reveals that several of the patients relatives have had similar episodes. Then I probably would have gotten it on these two. And then the last one is really just screaming. A urine sample collected turns dark after standing and testing reveals elevated porfinogen.

[00:05:31]Um AIP I think it's uh it's it's in season one of House. I'm pretty sure House's ex right the lawyer. and they have to like diagnose her new boyfriend and like House is jealous of him or something, but he's also having like the like the acute like paranoas and delusions and agitations and then they diagnose it by like collecting his urine and then like shining it up in like a window or something. But yeah, 45year-old man presents with jaundice abdominal pain and fever. Okay, so we're working with gallbladder eeology, right?

[00:06:08]I mean we're thinking we have backing up um of the liver. We're thinking we have probably like uh bilarubmia um something like kodokco lethiasis.

[00:06:22]So this is uh when you have a blockage from the gallstone of the common bile duct. So not only are you having um impaired bile secretions but you're also blocking the bile ducts that come out of the liver as well. The right upper quadrant ultrasound reveals dilated bile ducts and intrahypatic cholestasis without colithasis. So this is saying that they did an ultrasound. They took a look at the liver. The bile ducts are dilated which means that there is something downstream that's blocking it and intrahypatic colostasis which means that you do have like kind of biliary sludge sitting in there without colithasis which means that there's no stones visualized in the gallbladder.

[00:07:00]But again, all of that actually kind of still fits into the picture of kolecoiasis because your blockage is in the common bile duct which is way downstream which means that everything else upstream is being blocked. And I put down kodokco. So now we have to think of other things that can cause dilated bileducts and intropatic colostasis that's not kodokcoasis.

[00:07:21]What's the what's the the amoeba that makes like those liver paste cysts inside the liver? You know what I'm talking about? And I was thinking if you have one of those cysts and it's blocking up the ducks from the inside too. And and hyalitica. Yes. Yes. And hyalica, right? So you have these like stupid um Okay. Lab testing reveals mildly elevated a elevated ALP and einophilia. And anytime you see eosinophilia, you have to think about parasites. And I think somebody also said this in the chat. Clonorcus Sinencis, Chinese liver fluke, very famously um has an eosinophilic reaction. There we go. He reports that he recently traveled to East Asia for an exotic fishing experience. As you can tell, Chinese liver fluke is probably endemic to China. Uh stool examination reveals oval-shaped operculated eggs.

[00:08:14]Operculated is such a good word. I would not know what to do with that at all. I probably knew that at one point like second year of med school. Yeah, prazaquentel is just like uh antiparasitic. Uh we would use prazaquentel and you know drugs like alendazol. Um other things you've probably heard about are like ivormectin, right? And these really help you get rid of parasitic helmet infections. Honestly, if my antimea one was right, I would have gotten it in two. That would have been so cool. But uh eosinophilia definitely, you know, red flag for parasites right there. Um, 68-year-old man presents with sudden onset severe abdominal pain. Um, maybe we can do appendicitis. He's a little old, you know, for his appendix to rupture, but it happens. Appendicitis. A All right. He has a history of AIB, but denies any recent trauma or surgery. Oh, wait, wait, wait. This one's definitely messenteric eskemia. Yeah. [laughter] Okay. Okay. Okay. So infrequent painful bowel movements, abdominal tenderness, um pretty elevated lactate level that's showing that tissue is dying.

[00:09:21]Luccoytosis probably reactive from inflammation. And then the CT angio reveals an occlusion in the superior mesenteric artery. So this one just this one just straight up tells you like, oh, his superior mesenteric artery is blocked. And you're just supposed to be like, yeah, it's meantic eskemia. But [laughter] 34 year old man presents with fatigue, shortness of breath, and jaundice. I'm just going to say hpatopulmonary syndrome. That's that's a good one. They don't have hpatopulmonary syndrome. Um, congestive heptopathy maybe. All right.

[00:09:52]So, let's say congestive heart failure causing congestive heptopathy, reversal of flow. He's having right-sided heart failure leading to the shortness of breath and congestive hepatopathy leading to the jaundice. Okay, it wasn't that. [laughter] Ooh, wait. Cut 555 says alpha 1 antitripin deficiency. So A1AT actually does explain, you know, the wheezing and the hpatomegaly because you're it's the um it's the elastase damage, right? You would differentiate it from COPD based on if the like adalcttois is like panaciner versus lowar or something. I don't remember actually. You know, A18 kind of fits because it's it's lung and it's lung and liver. Alpha one antitripen deficiency. Is this another one where it's like I get it right in two and [laughter] I get it right in two and it's a little sus. Here we go. Yeah. The paninar ones.

[00:10:46]There we go. Okay. Causes emphyma and 30-year-olds no history. Yeah. So, I was here mild wheezing on lung oscultation.

[00:10:53]Then you're starting to look at obstructive lung disease. But why would you have obstructive lung disease with hepatomegal? Um, poor reversibility with bronco dilators means that it's not asthma and you're thinking more of a COPD. And if you're thinking COPD with liver, then that's probably going to be A18 deficiency. Um, so I think definitely doable at three. Two is excellent. Three doable. Uh, four doesn't really tell you anything, but five showing paninar emphyma predominately affecting the lower loes.

[00:11:20]I mean, that's literally what I was talking about, like the low bar versus paninar involvement. Um, so definitely you should be getting it in five because it's it's screaming at you at that point. So this is also where I remind everybody that I am an internal medicine hospitalist. All right, there is going to be a lot of times where I am probably going to run into a ped or an obgyn question on Dr. Dole and we will just have to deal with it. I don't know, man.

[00:11:47]We might end the stream here. [laughter] I mean 9-year-olds poor school performance. I mean, it could be ADHD, right? Because they're just like too they're too active and they Oh my god.

[00:11:59][laughter] Okay. IQ testing results are within normal ranges and he forgets to turn in his assignments. I think I could have gotten this at three. I don't know. Poor school performance is actually like you're probably thinking like ADHD, right? Because it's not like it's probably not an intellectual disability problem. It's more just like they can't focus kind of problem. So poor school performance. Actually, I I think I remember from like my board prep last year. Poor school performance. Yes, this guy's 9 years old, but I think there's like another one for like three-year-olds or fouryear-olds. If they present with these similar symptoms, like they forget to turn in their assignments or like they can't wait or like talk out of turn. Actually, sometimes it's just because they're too young. You know, like in America, like our our school year is like September to June, right? And which means that kids born in the summer usually get bumped to the next grade. But um sometimes, you know, if you have a kid in kindergarten, right, who's four years old or 5 years old and like they can't follow directions properly or like they're having trouble learning letters, sometimes it's basically just because they're like younger than they should be for school, right? So it's like you're treating a kid born in July um like the same as a kid born in September the last year, right? And that's almost like a whole year of development difference.

[00:13:21]So, so it's it's sometimes really just the age difference when you are that young that like makes it harder to learn in like a classroom environment.

[00:13:30]52-year-old woman presents with persistent night sweats over the past several weeks. Okay. So, we're thinking B symptoms, cancers, night sweats, I don't know, lymphas.

[00:13:42]Lymph lymphoma.

[00:13:44]Probably not primary testicular lymphoma in a 52-y old woman. We do like Hodgekin lymphoma. Maybe. No. She smoked cigarettes since the age of 18 and reports having a chronic cough for the past year. So, I'm going to say small cell lung cancer.

[00:14:01]Um, I mean, persistent night sweats is such a non-specific B symptom like fevers, night sweats, weight loss, all these things. Mucus producing and occasionally stre with blood. Honestly, night sweats and coughs stre with blood.

[00:14:17]I am kind of thinking more like TB actually.

[00:14:22]Let's just say TB. Tuberculosis.

[00:14:27]Oh, it was TB. Okay, nice. Um, she has not seen a doctor in several years. She recently immigrated from Mexico along with a group of laborers to work in the United States. A chest X-ray reveals cavitary lesions in the upper lobes of the lungs. So yeah, once it once cavitary lesions in the upper lobes of the lungs is not entirely pathommonic for TB but um cav TB cavitates uh which means it makes its own little pockets and it goes to the upper lobes of the lungs because uh TB is a aeropile. It likes oxygen so it wants to stay in those highly oxygenated zones in the lungs. um sputum staining positive for acidfast bacilli cuz uh TB like the bacteria stains positive um on that specific what is it like PIS test or whatever. [snorts] Yeah. 55-year-old man presents with chest pain, fever, and difficulty swallowing since his esophageal surgery 4 days ago. Ooh, bad.

[00:15:22]Okay. So, he had an esophageal surgery and like now he's got an infection. So, esophageal surgery, I'm not sure if it was like a nissen or something, but I would say like esophageal perforation, right? Uh, borhave syndrome definitely got to think about this when you have like chronic alcoholics or people who vomit a lot that can blow up the um esophageal lining and start leaking out into the medastinum. On exam, he appears ill, is tachicardic and tipnic and has diffused anterior chest tenderness. Is this just is this just mediainitis?

[00:15:57]Oh my god, it is all right. I I would have gotten that in one. I mean, like, yeah. So, chest pain, fever, and difficulty swallowing. You're worried about an esophageal pathology causing like a rupture of that system, like rupture, blow up, right? If you vomit enough or have enough increased pressure in that system, you can really tear the esophageal lining in half. And when that happens, all those contents are going to start leaking out into your medastinum, which is that chest wall space. um and you're start going to have infective content spill out there as well. Maybe he had some injury from his surgery or he had some, you know, weakness from that surgery and then all of a sudden things started spilling out and now he's got a fullon infection in the mediainum. 55-year-old man presents with left lower quadrant abdominal pain, fever, and nausea. So, left lower quadrant is pretty interesting. There's not usually that much going on there, right? Like right upper, you're thinking liver, gallbladder. Left upper, you're thinking stomach, epigastric, maybe you're thinking pancreas. Right lower you're thinking appendix. Left lower is really just your sigmoid colon, which is the part that's connecting your descending colon to your anus. Um, so it's sigmoid because it's like S-shaped and it kind of curves around from the left side of your abdomen down towards your rectum. Popular spot for diverticulitis. Um, diverticulosis is a common thing that happens in a lot of older adults. Um, imagine your colon is like a balloon inside of a net and when you blow up that balloon, you have these little out pouchings that are going through the net. That's essentially what you know straining is against like your um messenteric plexus, like all the muscles and the nerves around that area in the colon. So over 50 years of using your colon and straining and having bowel movements, you can develop these little outpings.

[00:17:49]Um and when these outpouchings get, you know, um like food or like peanuts is a really bad one. Um blocking those little out pouchings, then you end up or not peanuts, sorry, popcorns. When you get something like food or like popcorn, blocking those little out pouchings, they can uh get infected and lead to diverticulitis.

[00:18:11]um which kind of leads like this crampy abdominal pain with this infection. Um you're not completely pooping out blood, but usually what ends up happening is that you get GI to end up doing an e scope and they're just like oh it's just diverticulitis and you're like oh [laughter] I hope it's diverticulitis cuz that's this is a pretty good presentation for it. Yeah. So there's a very wide differential for left lower quadrant pain but diverticulitis is actually a pretty common reason for why people come in in here. uh physical exams revealed tenderness in the left lower quadrant with guarding but no rebound tenderness.

[00:18:43]So I mean it's it's got like diffuse kind of pain but uh it's really on the left lower quadrant where you're feeling tender around there but without any rebound tenderness I mean it's not like something is immediately dying rights revealing luccoytosis and a digital rectal exam is unremarkable. Labs revealing luccoytosis says that he's got a white blood cell count that's elevated probably because they're fighting off the infection and the inflammation going on. Uh CT shows thickening of the sigmoid colon with surrounding fat stranding. Yeah. So there is inflammation going on there. No evidence of abscess formation or perforation. So you're not worried about it, you know, blowing open um causing a connection from the gut and the rest of the pelvic cavity. You're not worried about an abscess or like an severe infection like that. And like I said, you manage this pretty conservatively just with antibiotics and fluids. So, he's managed with oral antibiotics and a clear liquid diet and he gets better. 70-year-old woman presents with itchy blisters on her arms, leg, and abdomen. Okay, so blisters, um, blisters are pretty specific. So, they're only two blistering diseases, right? Like you're worried about bullis pmpagoid or pmpagus vulgaras, right? Like again, think about this from like a med student level, right? like it's either PV or BP. Um, and you would basically differentiate those based on the Nicole skis kind which is uh you you scrape it away with your fingers and if it scrapes away it's one of them and if the other doesn't scrape away it's the other one. One of them is like a basement membrane problem. The other one is like a gap junction problem. Are gap junctions different from conexins? Are conexins different from desmosomes? I don't know.

[00:20:20]These are just like random random hisystologology dermatology buzzwords in my brain. [laughter] Dude, I'm not a dermatologist. I don't remember. Let's just say pimpagus.

[00:20:29]Pimpagus vulgaras. Me. All right. It's the other one. She reports that the blisters have been present for several days and are tense and not easily ruptured. So, it's bullis penmpoid. If it's not bullis pmpagid, I'm going to end the stream. I don't care. Okay.

[00:20:41][laughter] 34year-old woman presents with fatigue, palar, and exertional dispnnea over the past several months. Um, I mean, at the risk of being stereotypical, it's anemia. [laughter] 34 year old woman probably has iron deficiency anemia. Am I sexist? No, I'm not. All right. So, [laughter] I I was the paler that made me think of anemia, right? So, fatigue and exertional dispia could be a lot of things. You're thinking cardiovascular, you're thinking lungs, you're thinking like for a young woman things like pulmonary arterial hypertension or whatever. But, uh, palar like having paler skin, right? probably because you're anemic. Probably because you don't have enough hemoglobin going around your system. That's probably why.

[00:21:22]Heavy menstrual bleeding and occasional pah. I mean pah from the iron deficiency means you start eating things that have no nutritional value because your body is so starved for nutritional value and iron. A lot of times you'll see people like chewing on ice and stuff. Um conjuctal palar spoon-shaped nails. All these things happen. Microitic hypochromic anemia. So uh small pale red blood cells. low feritin because their iron stores are low and elevated TIBC because when your stores are low your capacity to bind iron is high. Um anoccytosis and pochilocytosis andytosis is just saying that you have red blood cells of all different shapes and sizes and some of them are tiny and spiky because obviously red blood cells aren't being produced properly here because you lack iron. So yeah, we give we give them iron and uh they get better. 60-year-old woman presents with abnormal uterine bleeding. Okay, this this could literally be anything. All right, let's It was just We were just talking about it, so let's just say endo. [laughter] Um, abnormal uterine bleeding means a lot of things. It can mean like bleeding outside of your normal psych. Oh, wait.

[00:22:24]She's 60. Hang on. She's 60. So, she should she should actually she should be postmenopausal. So, now we're now we're worried more about like a like a cancer workup, right? So, I mean um like an amometrial carma.

[00:22:39]I mean like an ovarian carcinoma. Uh that's not lupus.

[00:22:46]Um name name a name a uterine cancer.

[00:22:50]Uterine cancer. Uin car carcin carcinoma. There we go.

[00:22:57]Endometrial carcinoma. There we go. I would believe it. Ultrasound reveals a solid ovarian mass. Oh my god. All right. What are the What are the What are the solid ovarian tumors? There's like sex cord stromal tumor, but I remember doing that one with Brie, so I can't it can't be sex cord stromal tumor. There's a there's a theal thea thea tumor. Sex cord theoma. Ovarian thea ludian cyst. Sex cord granulosis cell tumor. Dude, it could be any of these. Granulosis cell. I Oh no. I don't I don't know. Oh no. Second question is already saying that she has a solid ovarian mass. So now we're we're just like running through like all the different ovarian cancers that I know.

[00:23:40]It's so it's one of these like solid ovarian tumors. I just I just don't know how to different Oh wait. Okay. I was going to say I just don't know how to differentiate between all of them. Um I think hisystologology of the ovary shows lipidladen stroal cells. This one is probably pathonommonic for sex cord theoma. Right. So a theoma is a tumor of the theal cells. The granulosis cell tumor is a tumor of the granulosis cells. Um, this benign sex cord stroal tumor is identified as a cause of the patients endometrial hyperplasia. Why is that written like a Jeopardy question?

[00:24:15][laughter] So, this one this one is like this one's like what is sex cordoma? But yeah, I mean I hisytologically I I wouldn't know how to differentiate between a granulosa cell tumor and a sex cordoma. So, if if lipidated stromal cells means anything to you, congrats.

[00:24:31]You're either a pathologist, a secondyear med student, or a gigantic nerd. 45-year-old man presents with several weeks of subtle clumsiness and occasional trouble finding the right words. Subtle. What does subtle subtle clumsiness even mean? Uh, okay. Um, occasional trouble finding the right words, I mean, makes me think of more like a stroke pathology, right? Like we're we're worried about like vertebrasler insufficiency maybe like TAS. I don't vertebrro insufficiency. Do they even have it? No, they don't have it. Uh maybe like corateed stenosis. Oh, they don't have corateed stenosis. Wow. Okay. Um see like hypoplastic basler artery. That's not one either.

[00:25:19]Ooh. Huh. Subtle clumsiness is more like an atexia. So like cerebellar evolvement. And then occasional trouble finding the right words is middle middle um middle cerebral artery involvement.

[00:25:30]Right? So that's that's brocas. That's word finding difficulty. Like subtle clumsiness. I'm not really sure if that's atexia or not. It's just like um it's that it's like a I don't know like what is subtle clumsiness? I've literally never heard something described as subtle clumsiness before.

[00:25:44]If I if I choose to believe subtle clumsiness is a taxia. How are you going to get a middle cerebral artery and a posterior cerebellar artery pathology at the same time? What about a deinating pathology? [laughter] I mean, I I guess it could always be multiple sclerosis. Oh, no. He denies fever or recent illness, but reports that his symptoms have been slowly worsening. Um, is it ever something viral like PML? It could be, but I mean PML, you need to be like a kidney transplant recipient or like pretty advanced HIV with a low CD4 count to be like imunosuppressed like like JC like BK virus, JC virus like they don't just occur in like normal 45year-old people.

[00:26:27]Brain tumor. Yeah. I mean you want to go gloma? We can we can do go or oligodendro. No. Oh my god. On neurologic exam he has mild right-sided weakness and expressive aphasia. Okay.

[00:26:40]So expressive aphasia means he can't get out the right word. So I mean this this doesn't really change anything. So he has right-sided weakness and expressive aphasia. So he's got right side symptoms from the left side of the brain and then non-dominant hemisphere affecting brocas. So like try PML. I mean do you have lesions reaching reaching around PML like lesions reaching around from the the cerebrum to the cerebellum? Oh my god. How did you get that? Okay.

[00:27:11]Okay. Okay. Hang on. Like four. His medical history is notable for untreated HIV with a CD4 count of 45. Like I I I literally said like you would only see this in like an HIV patient that is like completely imunompromised. Like I don't think you can get like JC virus or BK virus if you have a CD4 count above 50.

[00:27:32]So like 45 is like pretty bad. Okay.

[00:27:35]Like definitely definitely I could have gotten it at four, but I feel like getting it at three. Getting it at three is a little sus. I mean, this this probably points you towards it. And then this multiple asymmetric non-enhancing white matter lesions without surrounding edema. I mean, that's just like the definition of of PML right there.

[00:27:51]45-year-old woman presents with heavy painful periods.

[00:27:56]Uterine fibroids. It could be endo. Um chronic pelvic pain and disparunia. Um I mean we can go leoyoma fibroids here. Physical exam reveals a uniformly enlarged uterus. So leoyoma is you know just an overgrowth of the smooth muscle layer of the uterus. So usually in that case the uterus has more of like a lumpy appearance uh lumpy appearance because it's more just like little random out pouchings of that smooth muscle growth. Actually yeah if I said endo I probably also should have said I don't know. Oh nice nice. Okay.

[00:28:30]Yeah. So, um, [laughter] okay. So, I mean, I think if you said endo, you probably could have said I don't know after. So, definitely definitely these two probably doable. Uh, uniformly enlarged just pointing you away from leoyoma. Ultrasound ultra sound shows multiple areas of shadowing, which is basically just going back to the sixth question. So, it's it's endo, but it's growing inside the muscle layer. So that's that's where you're going to get adeno meiosis from. 62-year-old woman is found to have vague abdominal discomfort during a routine checkup. Um I mean we already did diverticulitis but very very common um presentation. Uh IBS IBS you wouldn't really see in a 62-year-old woman but um sure. All right. Physical exam is unremarkable but adexal fullness is Oh my god it's an obine question.

[00:29:25]Adinexal fullness is noted on bmanual exam. All right, so we're back to we're back to ovarian cysts again. Seriously, [laughter] ovarian corpus ludial cyst. Ovarian follicular cyst. Ovarian fica ludian cyst. I don't know man. Oh god. I know what other masses are there dude. I don't know. Are we are we are we worried about cysts? Cirrus cyst adenoma. [ __ ] it. I don't know. Like why why wouldn't it? Okay. I feel like I feel like you looked that up. How did you get cirrus cyst adenoma before this third one?

[00:30:00][laughter] How how did you like I mean like [laughter] All right, chat. My my eye is on you.

[00:30:13]Clearly clearly you guys just want me to keep going. [laughter] Six-year-old girl presents with small fleshcoled bumps on her trunk and arms that have been present for 3 weeks.

[00:30:22]Oops. Back to feeds. I mean, small flesh colored bumps for 3 weeks. I mean, that's like mlescum contag like pox virus, right? Like that's that's just like what it is, right? All right. Good.

[00:30:32]All right. I remember something from peds, guys. Yeah. So, I mean pox virus is a big fat virus. Um monkey pox, if you remember that was that was a thing.

[00:30:42]Remember when monkey pox was a thing? Um they're just really big viruses that live on the skin. Um they cause like inclusion bodies. I think it's really not. It's not that important. It goes away like Yeah. She is advised on hygiene practices to reduce the spread and to monitor for spontaneous re resolution. Yeah. 67year-old man presents with ur difficulty urinating and nocturia. Uh okay. So difficulty urinating and nocturia. First things you're worried about in an older man is BPH. So benign prostatic hyperplasia. Um the prostate gland is an enlarged gland.

[00:31:21]Uh oh. Okay, I got it right. The prostate gland is a little walnut sized gland that like sits in between um the uh bladder um and like the urethra. Um it kind of controls uh the open gates if you will for the urethra. So one way allows urine to flow through the urethra and out the penis. Uh the other way allows you know sperm and seminal fluid and semen to flow out of the penis. not really flow but you know what I mean. Um it enlarges with age, enlarges the testosterone exposure. So BPH is a very common thing that affects older men and an enlarged prostate starts pressing on your bladder starts giving you these um symptoms where you feel like you need to urinate at night or you don't fully empty. Um and yeah so uh weak stream sensation of incomplete bladder emptying was definitely what I just said. Uh monogous with a spouse of 42 years and denies any history of sexually transmitted infections. So prostatitis is definitely another possible thing. Um prostatitis usually is associated with STI. Um but obviously this guy there were two of them that just said he has no infection. So no disserior hematia or fever. You're not really thinking about a UTI or prostatitis either. Um digital rectal exam. This is what we do rectal exams for. All right. not only to look for poop, but to actually feel the prostate. And if the prostate is small and normal or large and boggy or um smooth, non-tender, or like hard and spiky, like those all mean different things. So, you know, benign enlargement, um prostatitis, prostate cancer, etc., etc. 35-year-old man presents with swelling in his legs and occasional headaches. He reports feeling more fatigued over the last few months. Okay, so we've got I don't know it could be like any nefertic thing. Let's just let's type in nefertic. So we've got membranous nephropathy could be uh diabetic glomeial nephropathy could be.

[00:33:25]We got burger. We've got um membranous nephropathy. We've got focal segmental glome sclerosis, elevated blood pressure and bilateral lower extremity edema.

[00:33:37]FSGS. Yeah, I think blood pressure is more of like an FSGS picture. Okay, cool. Yeah. 3 plus protein. So, um, he has a history of obesity and long-standing hypertension, but no known diabetes or autoimmune disease. So, I mean, the kidneys are going to be the ones bearing the brunt of that. And he's also on heart for HIV and has a history of heroin use. Uh, that is pretty on the nose. I feel like I feel like directly on pathoma it says that FSGS is associated with IV drug use and HIV.

[00:34:06]Um and then the sixth question says kidney biopsy says segmental glomearious sclerosis and hyelinosis with some glomemeili with focal foot processment on electron microscopy. So I mean yeah it really says it's focal segmental glomeular sclerosis. Yeah I mean it was this one this one definitely was pointing towards nephotic syndrome. So, I mean, if you just went down the list of nefotic syndromes, you probably could have gotten FSGS. A 55year-old man presents for a routine exam with no complaints. What the am I supposed to do with this? How is this a diagnosis? What what the do I do with this? How are you supposed to do this? I mean, may maybe it's like uh something that like you wouldn't like discover, right? Like maybe it's like lung cancer, right? And it's just like you don't um like what it's like adenocarcinoma, right? Like he has no complaints on his routine exam, but then you like 6 months later he like shows up for like a scan and gets, you know, found out to have lung cancer.

[00:35:01]Dude, what the is this? His history includes well-controlled hypertension and he takes leinipil. So he's fine.

[00:35:07]Dude, what the is this? Diabetes. Sure.

[00:35:11]Dude, I don't What What is this? Oh my god. Physical exam is unremarkable with a heart rate of 60. Firstderee AV block, right? First degree AV block is just asymptomatic bradic cardia, right? like sinus Brady and then you just deal with it. Oh my god, that was so stupid. What the [laughter] Why didn't you intro with this? Why did you give two lame clues? These weren't even clues. These were just statements, bro. He just wants to see you.

[00:35:41][laughter] So, brief loss of consciousness while shopping for groceries. I mean, we could just say vaso veagal syncopy. Wow. They don't they don't have any kinds of syncopy. Vaso vagal syncopy. No. Hello.

[00:35:51]Orthostatic hypotension after the patient stood up from the bottom shelf to grab wheat bread. All right, that's a good one. Right. He got he got the Mr. Krabs. He got dizzy and then he fell over. No. Okay. He reports a feeling of lightadedness before the episode, but no chest pain or palpitations. Uh lightadedness. So, I'm thinking like blood pressure, blood flow problem.

[00:36:13]Like, why isn't corateed stenosis a thing? Corateed sinus hyper sensitivity.

[00:36:18]This one's a good one. This one's usually like if they're wearing like a tie or something and then they pass out.

[00:36:23]Oh. Um, yeah. So, corateed sinus hypersensitivity. It's like the the blood pressure receptors on, you know, the corateed bodies are too sensitive, right? So, any sort of stimulation around them. So, yeah, you either find it with like people who wear like really tight ties or he was turning his head to the side to look for an item on a high shelf. So that position that he put himself in where he was turning his head to the side was compressing his corateed sinus and that's how he ended up passing out. Yeah. During evaluation, gentle pressure applied to the right side of the neck reproduces the symptoms and results in transient bradic cardia.

[00:36:57]Yeah. So this is what you're actually supposed to do to diagnose karate sinus hypersensitivity in the office. Uh remember to only do this on one side. Do not try to do this to both corateed bodies at once cuz that would be very bad.

[00:37:09]A 28-year-old woman presents with a painless bump on the dorsal side of her wrist. Ganglen cyst. I mean, it just has to be a gang cyst, right? Like, what what else could what else could this possibly be? [laughter] Like, this isn't even like a doctoral question. This is just like, do you know do you know what this is? [laughter] 44year-old man presents with recurrent upper abdominal pain and diarrhea. I mean, it could be like pancreatic insufficiency. Maybe that could be a good one. IBD. Yeah. Treated multiple times for peptic ulcer disease, but his symptoms return quickly after standard therapy. Uh what's the it's the it makes like uh it keeps making uh ulcers tumors. Uh what's it called? Uh Zolinger Ellison. Zolinger Zolinger Ellison syndrome. There we go. Yeah. So, this this one is literally just like you you have Oh, it's also associated with men one, but you you basically just have like this condition that causes you to make a bunch of ulcers and like you you really just [laughter] you really just have to give them as many PPIs as possible. 35-year-old man presents the ED with seizures and headaches that began 2 weeks ago. So, he's only had seizures for 2 weeks.

[00:38:21]That's crazy. So, yeah, like a brain tumor can cause seizures, but like 2 weeks ago. So um so you're worried about like maybe like an infectious growth. So I'm worried about like maybe maybe it's another HIV patient, right? Maybe it's like toxopplasmosis.

[00:38:36]So toxoplasma gandi can go to the brain cause these lesions. He has no prior history of seizures or neurological symptoms and he takes no medications. So um again it's it probably just telling you this is like an acute thing that happened 2 weeks ago. This is probably an infection. It's not toxopplasmosis.

[00:38:54]Uh, what else goes to the brain? What else goes to the brain? Uh, we already said PML for another one, so I don't think it would be PML. Uh, did wait, didn't I make a post about tenia tania? Like neur neuroscy neuroscytocosis?

[00:39:11]Oh, it is neuroscytoricosis. Okay.

[00:39:14]Neuroscytoricosis is um teniaolium, the uh pork tapeworm. Um, it's the one that you get from eating undercooked pork. um this one can go to the brain and start causing these cystic lesions. And anytime you have something growing in the brain or bleeding in the brain or pushing on the brain or just anything being in that brain space where only there's supposed to be brain and you have something else going on in there, it's going to cause different neurological deficits. Um and in this case, it's pushing on something and it's causing seizures um and headaches, too.

[00:39:49]But again, it only began two weeks ago, right? So obviously, this wasn't something that he's born with. You probably wouldn't have like a full-blown like mining or, you know, a glyopblast manifest in 2 weeks. So this is probably an infectious source. Tania causing neuroscytosis.

[00:40:06]Um, probably because he had, you know, oh, here he recently immigrated from Central America where he was an agricultural worker. So he he probably was exposed to it over there. All right.

[00:40:16]32-year-old man presents with a two-day history of malaise and agitation. Um, okay. Malays and agitation. So, he's lethargic. What? Malaise and agitation.

[00:40:26]So, he's he's just not feeling well.

[00:40:28]Feeling crummy and he's agitated. I don't know. Menitis. He reports recent symptoms of sweating, rhinora, abdominal cramps, diarrhea, and okay. Well, I mean, they literally just listed all of the symptoms of opioid withdrawal.

[00:40:41][laughter and gasps] Oh my god. Physical exam reveals dilated pupils, lacrimmation and pyo erection.

[00:40:46]Um, so that's dilated pupils, tearing and like hair on the end of the skin is standing up. Heart rate, BP are elevated, temp is elevated, symptoms improve with supportive care including anti-imetics like zopran and fluids. And he reports recently stopping heroin. So, this is why you don't, you know, instantly try to quit opioids cold turkey because this is, you know, a very real thing that happens to patients um when you're trying to taper off of opioid or, you know, substance use disorders. I mean, we try to get patients into methadone clinics or, um, give them a medication called Suboxone, which is a combined buponorphone um, medication, and it's a partial agonist in this case, and it kind of helps patients ease off of, you know, having all of these opioids in their system.

[00:41:28]So, they're not going from 100 to zero, you know, they're being gently weaned off. 65-year-old man with dementia presents with a 2-day history of fever following an elective colacyctomy. Okay.

[00:41:39]2-day history of fever following an elective colisectomy. So, you're thinking of posttop fever, right? So, it's water, wind, wabs, [laughter] um, walking, wonder drugs. So, two-day history. I mean, I mean, you could just have an infection, right? like a hospitalacquired infection some kind of nocomial infection two-day history of fever following an elective colacyctomy I mean what is what is posttop fever is it windwater webcess or water windscess I think it's I think it's wind water absess so you're thinking about like urinary tract infection I don't know why Dr. will specifies that it has to be an E.coli infection. What? Dude, I was so close. All right. Urinary tract infection. So, it is wind water. Wind water. Wabs walking wonder drugs.

[00:42:24]There's the five W's of posttop fever. I don't remember that much from my surgical rotation, but I remember that much. During the procedure, he had a fully catheter placed and complains of continued urinary discomfort. I don't I don't get it. How's it not a UTI? It's It's literally a UTI. He had a fully placed during the procedure and has had 2 days of fever since then. What the hell? Oh, you know what this is? Oh, uh, this is a interocous uh, anticocus vicalis. That is so stupid. That is so stupid because because Dr. Do only has E.coli UTI. Dr. Do only has E.coli UTI as a UTI thing.

[00:43:02]So for intericcus, you have to say interal infection. Okay. And terracus ficalis is a grandpositive bacteria that grows in um the biliary tree and it also can grow in the urinary tract.

[00:43:17]25-year-old woman presents with a firm irregular breast lump phoides phylois tumor. She was recently the restrained passenger in a motor vehicle accident. I mean we were just talking about pancreatitis and trauma being one.

[00:43:32]So uh breast fat necrosis I think is probably the answer. Yeah. So, when a patient is sitting in a car and you're wearing your seatelt and you suddenly have that immediate trauma to that area, you can actually like cause the fat to basically burst essentially and soponify. And that trauma is enough to basically set off this necrotic reaction where more dying cells are going to chain react and cause more dying cells and everything. So these micro calcifications and these lipid laden macrofasages and necrotic atapost tissue is just more breakdown of breast tissue and the macrofasages that are trying to clean the space up. But uh yeah fat necrosis from trauma definitely real thing. It's essentially the same thing for pancreatitis. You would get the pancre pancreatic fat necrosis from trauma like a seat belt as well. All right, that one's pretty straightforward for a firm irregular breast lump. The fact that they give you motor vehicle accident in the second one I feel like that could have been a lot worse. A 29-year-old man presents with rectal discomfort and a sensation of incomplete evacuation. Okay. Internal internal hemorrhoids. Internal hemorrhoid is a good one, right? Because if they're pooping and they're feeling it kind of like plopping around in the rectum, intermittent teneesmas and mild rectal bleeding for the past 2 weeks. I feel like that's still valid for internal hemorrhoid. Uh I feel like cuz external hemorrhoids are painful and it's discomfort and sensation of incomplete evacuation, right? It's not it's not exactly painful. Um a lot of people overlook procitis. Um that's that's a good one. Oh, okay. It was proctitis.

[00:45:13]All right. All right. There we go. The patient reports, "I've noticed a slimy or sticky coating on my stool. He denies weight loss, but reports recent receptive anal intercourse without condom use." So I mean uh flexible sigmoidoscopy shows arithmetus friable mucosa limited to the rectum. So it's all it's all you know happening in the mucosal layers in that area. It doesn't go any higher but it's not going any lower. Um so you're basically just having a local infection. 76-year-old man presents with persistent back pain and fatigue progressively worsening over the past several months. back pain and fatigue. I mean, there's so many things. I don't know.

[00:45:53]Like, back pain and fatigue, like degenerative joint disease or something.

[00:45:57]I mean, he's old, right? Degenerative disc. Degenerative joint. They don't have anything. Lumbar lumbar disc herniation, maybe. I mean, that's not really pain. It's more like sciatica, but laboratory studies reveal a hemoglobin hematic grid of 10 and a serum calcium of 12.1. Okay. So, now I'm thinking more like multiple myyoma.

[00:46:16]There we go. All right. So, elevated serum calcium, uh, it's one of the crab signs of multiple myyoma. Multiple myyoma is a, um, it's a cancer of the B cells in your, uh, bloodstream, like the, um, cells that produce antibodies.

[00:46:35]Um, and basically, you're going to have a growth of these cells where they just start producing out a bunch of junk antibodies, and that clogs up your kidneys, causes kidney damage. um you're ending you're going to have these lesions in your in your bones um and it's going to spike your calcium levels.

[00:46:53]Um and you diagnose this by trying to find a spike of amunogloabbulins. So this is what the serum protein electropheresis the SPE and the upupep end up doing together. Uh they help you identify which antibbody line is being overproduced here. 58-year-old woman presents with non-specific pelvic discomfort. All right. I a dude this could be so many things. I told you I was going to go out on a gynecology question. All right, so I guess we can start with ovarian cyst maybe.

[00:47:26][laughter] Uh a firm adexal mass is palpated on pelvic examination. That is literally how all of the other gynecology ovarian cyst questions started. ovarian.

[00:47:39]Well, if it's not a corpus ludial cyst, maybe it's a thealudian cyst. Oh my god.

[00:47:44]Pelvic ultrasound demonstrates a small solid hypoacoic ovarian lesion. Oh my god. All right. Well, if it's not a corpus ludial cyst and it's not a theoludian cyst, then maybe it's an ovarier follicular cyst. God damn it.

[00:47:58]What the [gasps and laughter] How many different ovarian cysts are there? She denies weight loss, early satiety, or bloating. Hey, so it's it's it's [laughter] a it's a cyst. It's not a it's not a cancer. All right. It's probably not a tubo ovarian abscess because she's not coming in with fever.

[00:48:16]So it doesn't look like a sign of infection. Cirrus cyst adenoma cycis mucinist cystinoma dermmoid cyst. Oh my god. Mature cystic territo. Oh my god.

[00:48:29]It it could it could be any of these.

[00:48:32][laughter] I think we already did cirrus cyst adenoma for one, right? Okay, so dermmoid cyst and mature mature cystic territo are basically the same thing, right? Like isn't a isn't a terteratoma a type of dermmoid cyst? Oh god, I don't know any of this. Dermmoid cyst hisystologology reveals nests of epithelial cells with grooved coffee bean nuclei. I I have no idea what that means.

[00:48:55]>> [laughter] >> I feel like if you're if you're a pathologist or an obgyn, like you probably instantly know what this means.

[00:49:04]I I have I I have no idea what this is, guys. Coffee bean nuclei. Cyst. I guess cirrus cyst adenoma or mucinus cyst adenoma wouldn't have coffee bean nuclei. Feel like a mature ter like a terteratoma does not have coffee bean nuclei. I genuinely don't know what coffee bean nuclei is. [laughter] Well, it's nests of epithelial cells. Is nests of epithelial cells going to be a cancer? Why? Why is there no cancer?

[00:49:30]Ovarian cancer. Why? Why? Carcinoma. All right, here we go.

[00:49:38]Me. Hio carar. No, it's it's an ovarian lesion. Uh, mucinus carcinoma, cirrus carcinoma, emnal cell, mucco epidermmoid carcinoma.

[00:49:51]I I don't know. I think I think I think it's time for bed, guys. I don't have a good answer. [laughter] Mucco epidermmoid, right? Because it's got epithelial cells. Mucco epidermmoid makes sense. These cells resemble transitional epithelium and the excised tumor demonstrates benign features.

[00:50:09]What? So, it's it's it's not a it's it's benign. So, it's it's uh what? But transitional epithelium should not exist in the ovary. So this is a tumor. It's metiplasia turning the it's metiplasia turning the ovarian tissue into a transitional epithelial tissue.

[00:50:32]Transitional epithelium is like uh the bladder, right? So it's it's something that can stretch um and your the cells in there can like stretch and squash which you know for the bladder because it expands and you know retracts as you have more urine and expel urine it's fine but like obviously you don't want your ovary cells turning into transitional epithelium. I mean it's it's a it's not cancer. It's metiplasia but it's like met ovarian metiplasia an answer. Oh my god. All right. I think I think it's dunzo. I I think we lost. Uh I don't even know what this is. Like again, I'm sure if you're a pathologist or obgyn, you see coffee bean nuclei and transitional epithelium and that just like instantly means something to you.

[00:51:13]But this this is like this is meaningless to me. [laughter] All right. Uh mucco epidermmoid. What was the other one? Cirrus. Cirrus cyatenoma. Cirrus. So it's transitional epithelium. I don't know. Game over. The diagnosis was Brener tumor. What the is a Brener tumor? I don't know what this is. Uh, a Brena tumor is an uncommon predominantly benign type of ovarian surface stromal tumor. Okay, fine. Give me give me some hisytologology. All right. Well, so nests of epithelial cells with bean nuclei. Oh my god.

[00:51:50][laughter] Well, I mean, when you when you put it like that, yeah, it makes sense. Benign but sometimes malignant ovarian Brener tumor named after Fitz Brener. Some of the nuclei have a longitudinal groove similar to the groove found in a coffee bean. It was good while it lasted. We tried. We were We were finally defeated.

[00:52:10]No.