Dr. House

rifk

Yeah, as I expected, this final diagnosis would be very hard to figure out. So the mass in the eyes isn't a neoplastic growth, which is why i said they didn't appear neoplastic and looked more like knots of the capillaries in the retina. These knots represent a growth known as angiomatosis. Angiomatosis, Pheochromocytoma, and Renal Cell Carcinoma combined are common symptoms for an extremely rare genetic condition called Von Hippel-Lindau Syndrome. It's a hereditary genetic defect in the VHL tumor suppressor gene, inherited via a dominant inheritance pattern. This explains why the mother of the patient died of Renal Cancer, implying that she also had Von Hippel-Lindau syndrome. Since it is a dominantly inherited genetic defect, only one copy of it was required to have the disease, which is why the patient has it despite how his father lived a long life and died from cardiac problems. Tumor suppressor genes normally help to maintain fidelity of the genetic code. A mutation such as in the VHL tumor suppressor gene predisposes the patient to additional mutations causing them to exhibit the symptom of multiple tumors developing in different organs. For some unknown reason, many patients with this disease suffer from pheochromocytoma, renal cell carcinoma, and angiomatosis. The unfortunate thing about this disease is that there's no cure for it. Only thing that can be done for these patients is to excise the tumors and have them come back to the hospital for occasional checkups and tests to ensure that the tumors don't return, and that new tumors don't appear. Thus, Final Diagnosis: Von Hippel-Lindau Disease. Overall, I'm impressed that everyone figured out all the individual symptoms. Those are the more common things you see in clinic.

If noone gets it in ~an hour or so, I'll just post the answer so you can read about it if you're interested.

No hemorrhaging in the retina. They just look like swelled up knots of the capillaries near the retina.

Typical presentation of retinoblastoma is childhood onset of a tumor of the retina. Typically it causes blindness and high rate of metastasis. After excision of the primary tumor, patients with hereditary RB can potentially develop tumors elsewhere later on in life, usually osteomas. Our patient, on the other hand, does not have any significant past medical history, no history of childhood illness or surgery such as RB. Patient also does not report any problems with his eyesight despite the capillary masses.

I think this final diagnosis will be very hard to do, cause it's extremely rare. Good job on getting this far and singling out pheochromocytoma and renal cell carcinoma as the two causes of high blood pressure despite a significant drop in hemoglobiin and RBC levels. The reasoning behind this is that you have neoplasia in two separate organs that could be seen by CT scan. Logically you'd think it was metasis from one organ to another, but pathology of the biopsy actually showed that the histology were of two different types of tissue. It would make sense because renal cell carcinoma would cause the kidneys to shut down, causing dark urine due to problems filtering out the blood, elevated BUN and creatinine due to the kidney's inability to function in filtering out toxins from the body. In addition, one very important function of the kidneys is to secrete erythropoietin. Erythropoietin is the compound responsible for synthesis of heme rings component of hemoglobin. Lower than normal levels, naturally would result in deficient heme synthesis resulting in the low hemoglobin and RBC levels. Pheochromocytoma is a cancer of the adrenal medulla, one that causes overactivity of the cells. Thus, since the primary function of the adrenal medulla is secretion of catecholamines such as epinephrine, pheochromocytoma would result in large levels of catecholamines being released. The effects of this increase in catecholamines would increase arteriole constriction, cardiac contractility, and rate of SA node depolarization yielding tachycardia and elevated blood pressure. The final thing to add is that when we check for metastasis, we always look at nearby lymph nodes to determine whether there is metastasis. This turned out to be negative which means that the growth in the capillary bed of the patient's eyes are actually a third growth. He denies having any symptoms which means that it may not be a neoplasia. So, the patient essentially has three abnormal growths going on at the same time. A patient 34 years old who, normally would not have to worry about cancer for another 10 years, has multiple types of cancers simultaneously growing. What would cause a patient to have these symptoms and this family history?

Hemorrhaging would account for the low RBC and hemoglobin levels, but not the low erythropoietin. Renal cell carcinoma causing the kidneys to fail causes low levels of erythropoietin, which in effect lowers synthesis of hemoglobin and RBC. Pheochromocytoma would indeed cause the severe hyptertension. Thing is, what would cause a patient to have two different types of cancers developing simultaneously? Cancer is normally a disease associated with old age. This patient is 34 years old, chances of him developing one type of cancer is already rare, much less two, possiblly three types of abnormal growths if you could the one in the capillaries of the back of his eyes.

His pulse is over 100, tachycardic as shown by the rapid EKG. P-R Interval 0.16sec, QRS complex 0.12 sec, no signs of bundle block or atrial fibrilation. However, EKG shows that it's sinus rhythm tachycardia, which is consistent with pheochromocytoma, which we already proved.

Workplace is a typical office building, built around 10 years ago when the dot com boom took place. No signs of asbestos or lead paint in the walls. Building has passed its annual inspections every year. Noone else in the workplace reports having been sick with anything remotely related to what the patient has. Tox screens are negative for heavy metal poisoning.

Cataracts is the clouding of the lens in the eye, not a mass seen in the back of the eyes. Also, even if it was cataracts and not a tumor, it still wouldn't explain how the patient has two different types of cancer simultaneously. The chances of that are extremely rare.

If these tumors keep popping up, you're probably not that far off.

Pheochromocytoma, not a bad idea. Cancer of the adrenal gland would explain the huge excess of catecholamines in his blood and his severely elevated blood pressure. It's very unlikely that he would have two different kinds of cancers at the same time, but for the sake of being sure, a biopsy of the masses in the left adrenal gland was done, and sure enough, pathology confirmed that it was consistent with pheochromocytoma. So, we have a patient that has two different types of cancers simultaneously. They explain all of the symptoms except for the fact that he has an additional mass in his eyes. Even if we were to explain that by metastasis, it is still extremely rare for someone to have multiple tumorous masses growing on two different organs, both of which are confirmed to be of a different type of cancer. Any ideas?

Normal BP for a typical person is 120/80. He reports that he doesn't really go to the doctors that often and until recently, he hadn't gotten his BP checked in years. Last time he had it checked, he said it was around 110/75

Biopsied the tumors in the kidney, pathology found that they were consistent with renal cell carcinoma. We've determined the cause of the elevated BUN and creatinine. But the patient's severely elevated blood pressure and elevated levels of catecholamines is still a mystery.

8 hour fasting glucose level of 80 mg/dl (normal) and 2-hour oral glucose tolerance test of 120 mg/dl (normal). He's not diabetic.

Protein shakes would explain the elevated BUN levels, but not any of the other test results. Caffeine from energy drinks could raise blood pressure and heart rate, but won't explain any of the other symptoms.

No significant drop in white blood cell count in the lab results, no drop in CD4 cell count.

That's a given.

If any of the mods feel like this is cluttering the forum, feel free to move it to flames forum as needed. Patient, 37 year old male admitted to the hospital with a multitude of symptoms. He came in complaining about pain in his loin region, weakness, and dark colored urine. Upon physical examination, the patient's blood pressure was 220/100, heart rate was 150 bpm. A small mass was detected upon deep palpation of the upper left abdominal quadrent. Also, examination of the eyes with an opthalmoscope demonstrated a small unusual mass. Labs were ordered and came back with the following significant results: Elevated levels of catecholamines BUN 110 (Elevated) Creatinine 4.1 (Elevated) Hemoglobin 6.2 (Low) RBC 3.1 (Low) erythropoietin 5.1. (Low) We do a CT scan of the upper abdominal region and found that there wasn't just one, but multiple masses located in the left kidney and also in the left adrenal gland located immediately superior to the kidney. Patient denies taking any medication other than tylenol for fever due to the occasional flu or cold. Patient works in software engineering and although he says he tries to maintain a healthy diet, he admits to not getting as much exercise as he should. Family History: Patient does not have any siblings. His father died from myocardial infarction at the age of 80 and his mother died from renal cell carcinoma when the patient was only a child. Since I don't have as much time anymore as when I was on break, I've posted pretty much enough information that with research, you can determine the final diagnosis. Once again, if you ask for any tests or details, I'll provide the results. So, what's your differential diagnosis?

Attn: Haubitzer, In order to continue your request to join as an official member of myg0t, you must pass a pre-initiation physical exam. Because raging can be taxing on the body, myg0t requires that all members be in top physical shape. Please contact me to set up an appointment so that I can evaluate your medical health status.

http://www.youtube.com/watch?v=3E-pHMN4DyA

I don't normally make threads like this, but this stood out. http://www.dailymail.co.uk/news/worldnews/article-1113188/American-woman-22-auctions-virginity-2-5m--waiting-better-offer.html So, guys, how much would you pay to fuck this chick?

So I'm guessing you're ishbu, and the other new poster is twolvesfan? Or did I get it reversed?

http://msnbcmedia2.msn.com/j/msnbc/Components/Photos/060905/060905_ritalin_vlg_9a.widec.jpg