Indiana University School of Medicine - Caduceus Yearbook (Indianapolis, IN)

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Clinical-Pathologic Conference, I.U.M.C. Clinical Presentation: Dr. John T. Scutdoer, MCCH boy April 14, 1972 Case Discussants: Dr. David O. Challenger, Almost-a-Chairm an and Healer-at-Large Dr. Stanley Battered. Chairman Emeritus, National Committee for the Bewildered Dr. Walter J. Dildo, Alleged Chairman of Medicine, BON VI- VANT Dr. Roscoe E. Killerfiller, Renowned Rectal Ra- diologist Dr. Joshua You-Know, Physician in Chief of you-know-what DR. SCUTDOER: This is the first Indiana University admission for this forty-four year old, semi-retired, known veteran, whose chief complaint was. I been trampled. For several years this patient has suffered from paroxysmal attacks of rectal wheezing. The recurrent nature of these attacks lead him to consult a physician who diagnosed his case as that of being Congenital Flatus Imperfectus and recom- mended a diet fortified with cabbage and milk. This regimen has minimized the sequelae of this process. On 1 April, 1972, the patient noticed the sudden onset of retrobulbar pain on micturition, PRURITIS DENTII. and fluorescent stools. This symptom complex prompted the patient to seek assistance at the Indiana University Medical Cen- ter. Unable to obtain assistance, he was thereupon seen at the Veteran's Hospital. While seated in the corridor, the patient stated he suddenly heard hoofbeats which progressed in intensity and lasted a total of thirty to forty-five seconds and gradually faded away. At the peak of intensity, the patient experienced a sud- den. severe chest pain in his mid-sternal area which was characterized by a feeling like he had been kicked by a mule. This lasted approximately 10 seconds during which time the patient was violently pushed back to the floor. Unfortunately no one actually witnessed this episode, but several physicians, nurses, and VA assistant assistants stated that they had heard the hoofbeats, and it was observed that a new pile of fecal matter was present some feet from where the patient was found. Specimens of this material were sent to the laboratory where ultracentrifugation was performed and viral and bac- terial isolates were prepared. The fecal chloride was one hundred and one, the sodium was one hundred and forty-two, the potassium was 1.8, the calcium was 9.1, the urobilinogen was less than two Ehrlich units, and undigested Mother's Oats were noted in the sediment. The total sample weighed 1.1 kilograms. The patient was admitted immediately to the medicine ICU. On physical examination, nasal obstruction was present, much more marked on the left, with a slight, bloody mucoid discharge. At this point surgical consultation was obtained to remove the patient's finger. Other pertinent physical find- ings at this time included the peripheral stigmata of the routine veteran's syndrome. Also there were three small horse- shoe-shaped bruises in the mid-sternal area with erythematous purpuric lesions symmetrically arranged at the periphery. Stains of the sputum revealed numerous Gram-positive cocci, Gram-negative rods, and one AFB which was seen on the fifteenth sjide prepared by the junior medical student. Laboratory studies at this time included electrolytes, BUN, CBC. Australia antigen, Five-hydroxy-indole-acetic acid, C.omer activating substance titers, pregnancy test, and supine stool velocity (because of the emergency nature of the sit- uation. ) All orifices were intubated and flushed on a fifteen minute emergency basis. Despite the repeated laying on of hands and Gregorian chants performed by the intern, the patient followed a rapidly uphill course terminating in RIGOR MORTIS. DR. DILDO: Thank you very much, Dr. Scutdoer. We have today for our perusal an exceptionally, I would say an extra- ordianrily, I would say a supremely interesting case of a middle-aged, semi-retired veteran who died suddenly after an episode of paroxysmal prostration accompanied by hoofbeats. May we review the X-rays and the Electro-seismograph?

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At last---1 think. 19 I matched as janitor at IUMC!

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DR. KILLERFILLER: As an opening comment here I feel compelled to mention that although we in radiology arc con- sidered technicians and are often maligned, you will notice upon whom the clinician called first. Now in reviewing these Barium contrast studies, we must, first of all, make the judgment that they are totally inadequate, as they were not performed by my loving hands. However, we will, with this despicable preparation, attempt to make some semblance of a diagnosis. I will say, that although the patient was poorly prepared, they are consistent with, but not diagnostic of, normal. Now with reference to the chest X-ray, which I'm sure you gentleman were convinced I would not be able to read. I must make note of the fact that there is an old, calcified granuloma present in the apical, posterior segment of the . . . left upper . . . right upper . . right side of the chest. In closing I feel as if I must once again review the proper order of X-ray procedures . . . DR. DII.DO: Although no direct tracing was made at the time of the patient's acute attack, an ESC was being taken while the nurses were rapidly preparing to prepare a bed for this dire emergency. At the time that the hoofbeats were heard, a rhythmic, two-second oscillation appeared on the tracing superimposed on the non-specific ST-T wave changes. These findings are compatible with hoofbeats, but I would have recommended serial tracings. DR. CHALLENGER: Dr. Dildo, 1 would like to point out that the two-per-second oscillations, superimposed as they were on the non-specific ST-T wave changes, could lead to some confusion in the diagnosis. Albeit, you may be right concerning them being compatible with hoofbeats, I must report that in some unpublished reports containing uninterpretable data, the concommitent presence of either B 52's, sunspots, or tornadoes must be excluded. DR. DILDO: In a series of 14 former patients here at IU, all of whom presented with a history of prostration occur- ring seconds to minutes to hours to days after hoofbeats were heard, it was found the 6 had been trampled by cows, 4 by sows, 1, a zoo-keeper by trade, by a zebra, 2 were found to lie malingerers, and one had made an indecent proposal to a student nurse. Unfortunately, in only two of these cases were fecal specimens obtained, and in both cases analysis and crapochromatography showed values very much like those noted in today's case. In neither case, however, is the potassium below 2.3. Well now, how about the fecal specimen, uh, Dr. Joshua You-know. DR. JOSHUA YOU KNOW: I'm very glad you asked me that. We've just finished a study on this subject, since I've been formally interested in crap metabolism for years and we find that 83.8' of the time, day or night, fecal matter can be found in the halls of the Veteran's Hospital. This proved to be unidentifiable as to source most of the time. DR. DILDO: Dr. Battered, would you care to make a few timely, pungent, pithy comments concerning this case? Will someone nudge Dr. Battered, being careful to avoid his sterile shawl. DR. STANLEY BATTERED: There has been noticed in the literature over the few years, and I've had fifty cases my- self, of FLATUS IMPERFECTUS in which it is know that there is an increased susceptability to trampling. DR. DILDO: In light of these findings, I am inclined to totally ignore the surgeon and disregard the afore-mentioned crap-analysis. As for the hoofbeats, this is anotoriously unreliable sign. However two facts are pertinent. First, the sow-show anually held at Ball Residence was active at this time, and secondly, there were two zebras housed as color- ful reminder for the residents of the sixth floor. I have to conclude, therefore, that this patient had been trampled to death either by a sow or zebra. In summary my diagnosis is paroxysmal protoplasmic insufficiency secondary to trauma, porcine, zebrine, or bovine. DR. JOSHUA YOU-KNOW I have a few slides here. The pathological diagnosis was golloping consumption. Today's case has, of course, come as a surprise to most of you. In retrospect, I think more attention should have been paid to that sputum stain. That AFB turned out on culture to be MYCOBACTERIUM BOVINUM. I think that there can be no doubt that the hoofbeats were indeed bovine and on autopsy, the diag- nosis of acute massive miliary TB was, of course confirmed. All CLINIC IANS have been fooled many times by the protean manifestations of this dread killer disease. Once again, this great deceiver has outwitted and eluded our finest diagnosticians. V Mil jut X nv MM ■«-