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

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Case Records Of The Wizard General Hospital Daily Clinicopathological Exercises George Burns, Editor Case 1-1978 A 25 year old male medical student was admitted to the hospital complaining of flickering vision . This fine, but cranky young fellow was in relatively good health until the day of admission. After being on call the preceding night, he began complaining about the cold, snotty eggs being served . Those about him perceived that he was suffering from quite a bit of flatulence that morning. Suddenly, he complained of a chill going up his spine and of a severe headache. Shortly thereafter, he began to express copralalia, uttering: we're getting the shaft , and this hospital sucks ! He continued to express this air late into the morning during staffing (grilling or straffing). Suddenly he moaned, Why are the lights flickering? He then grabbed his head and sunk to the floor. He was dire ly admitted to the hospital (via the E.R. of course). He did not pass go, but he did have to pay $400. Upon examination, the chap appeared glassy- eyed and dazed. Vital signs were normal. Gooseflesh covered his pale body. Pupils were equal, anisocoric, but responsive ( a beer can in view caused mydriasis - Cole's sign). Fundascopic exam showed the arteries to be slightly pale and the disks showing signs of papillitis. The visual fields were diffusely obscured, and the patient stated that he couldn't see for shit . With the exception of rather massive flatus, the remainder of the physical examination was normal. Throwing caution (and money) to the wind, laboratory studies were ordered. No test was left undone. Important data included: WBC 15,000 with left shift and 1,000 eosinophils; SGOT 50 mg%; BUN 25 mg%; Molybdenum 2 mcg%; Blood cultures (X6 for reproducibility, of course) did grow several strains of coliform bacteria; CSF studies including an opening pressure of 10 mm, glucose and chloride were normal except WBC count of 1,000: Microscopic exam of the CSF showed no remarkable findings; EKG showed normal sinus rhythm: Chest roentgenogram was unremarkable; However, the skull films were quite interesting. Please see figure 1 below: Figure 1 Right lateral view of the patient's skull demonstrates a large lesion in the area of the anterior communicating artery in the Circle of Willis. 26

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On the opposite page, you will see polygraph recordings from each of three unfortunate dogs. Note that certain treatments have changed the course of their EKG's. Below you will find a list of the possible treatments. Please indicate what treatment was given at each of the four intervals: Possible treatments: 1. Sub-lingual application of phentolamine. 2. Rectal application of Sominex. 3. Cutaneous application of Sherwin-Williams powder blue . 4. LSD (given any old way). 5. Extract of Exxon (given at great expense to the patient). 6. The dibucaine number. 7. I.M. injection of tincture of Colgate. 8. Inhalation of one mole of Los Angeles' rush-hour air. 9. Solution of Schuster's BBV (building block virus). 10. Bringing nurse to bedside of 91 year old male. The correct answers are (of course): 1 - 7 II - 9 III - 5 IV - 10 Aj spatue V)Ot vA ET ! SO S CT OJ AAX. 25

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Differential Diagnosis Dr. H.R. Glowbox: The striking lesion seen on the film is located near the anterior communicating artery in the Circle of Willis. I know of only one disease entity which could cause the response that we have witnessed today. Fortunately, today we have in our midst a renowned neurologist, Dr. C. Rebrum. Dr. C. Rebrum: Ya, Ich bin Hier. But I am too excited to speak!!! My associate must speak for me. Dr. Tref Ihnation: The amazing entity which was first described by Dr. Rebrum is the infamous Wamper's Syndrome . The pathophysiology is that through a small venous fistula a fecal embolus from the rectum enters the paravertebral venous system, from which, after ascending, it enters the vertebral artery via an arteriovenous malformation. From there, the embolus enters the Circle of Willis. Here, the embolus goes around and around (going wamp, wamp, wamp ) and sometimes it can occlude the ophthalmic artery, such that the patient can't see for shit , and is often is described as having a shitty outlook on life . It is a terrible but transient disease, which usually disappears shortly after leaving the hospital. Of course, massive doses of corticosteroids and ampicillin are necessary. Unfortunately, those struck by this malady often have recurrent episodes of carbbiness which characterize what some call Mecca Madness . 27