23. The First Round


It was a fun weekend at Brooklyn Hospital. It was time for Diagnostic Challenge Tournament, meaning all residents from different specialties came together to participate in a competition. Usually one of the attendings was responsible for presenting a few cases and the residents were divided into groups to try and solve the case. We were gathered in the conference room waiting for it to start.

'Morning, doctors!' Dr. Rivers came in and got up on the stage. I didn't know he was the one presenting so it was a nice surprise. 'Everone has a group already?'

I winked at my crew. Peter, Jax, Kate, and me together once more.

'Okay, so today we have three cases with almost the same complaint. You know the drill, first the history and physical and you all need to cast your best bet on what is the final diagnosis. After that, I will give you the labs and the second round of guessing takes place. Two points if you're right in the first round, one point if you're right in the second round, and three points if you're right in both. Questions?'

All residents nodded and we all started chatting as he wrote in capital letters on the whiteboard the central theme of that day: FLUSHING. 

I smiled. Dr. Rivers liked discussing weird symptoms but this time he outdid himself. Flushing alone didn't make me think of many differentials. I was excited to start.

'Ok, doctors, so your first patient is a 55-year-old male, let's call him John, who comes to your office because of intermittent flushing for the past few months. He said he experiences a sensation of warmth and sweating many times a day without any precipitating factors. He has no other complaints except for diarrhea that has been bothering him for the last few weeks. He has no history of illness and denies any medication use. Open for questions.'

A ton of questions emerged and all groups started discussing possible diagnoses.

'Well, flushing is usually caused by benign things like fever, medications, or even emotions.' Jax started. 'But I'm guessing Dr. Rivers is going for something more complicated than that.'

'I guess so.' Peter said and we started what seemed like an endless discussion about flushing. Until Peter had an idea.

'Maybe it's easier if we consider what comes together in this case. He also has diarrhea with flushing.'

'You're right, Peter!' I joined. 'Diarrhea and flushing usually mean there is something hormonal going on. Hyperthyroidism?'

'Maybe. But it causes more sympathetic tone and vasoconstriction. Flushing is usually caused by vasodilation. What else?' Peter continued.

'Hum… I guess there is one diagnosis I remember but it has a little bit of a Peds bias.' Jax laughed. 'Mastocytosis. It can cause vasodilation, hypotension, diarrhea, tachycardia.'

'Nice!' Kate wrote it down in our sheet as a possibility. 'But you're right, more common in children. My turn now.' She smirked. 'Diarrhea and flushing make me think of VIPoma. Pancreatic tumor secreting vasoactive intestinal polypeptide (VIP) causes watery diarrhea, hypokalemia, and achlorhydria. It can also cause flushing.'

'Smart.' I said. 'But how are we going to differentiate those only through symptoms?'

'We could guess one of those and wait for the second round.' Jax said just to tease me. He knew the competitive Lisa inside me wouldn't be happy if she got it in the second round.

'No way, Jax. There is got to be a way for us to find out. If there was no way what would be the point of the first round?'

'Let's read the case again then. We were so focused on flushing that maybe we missed something.'

We got our sheet with the written case. We went through the notes we took as other groups asked about the physical exam. 'Scattered wheezes and diastolic murmur.' Two questions popped up in my mind at that point. How did we miss this? And maybe more importantly, why did this matter?

'Okay, so does any of these signs make you think more of one of these conditions?' I asked and we were all left thinking for a couple of minutes.

'Neither!' Kate shouted and woke us from our mindless wondering.

'What do you mean?' Peter asked.

'This makes me think of neither of those. Think about it. Flushing, diarrhea, wheezing, and heart murmur.'

'So John has Carcinoid Syndrome.' I completed. 'And I know how we will know for sure.' I smirked and walked to the stage to ask one more question.

'What side is the murmur?'

Dr. River smiled at me and pointed to his right side of the chest.

Carcinoid syndrome is usually associated with metastatic tumors originating in the intestine that secretes serotonin or other chemicals into your bloodstream causing symptoms, especially wheezing and right-sided valvular heart disease. The left side is usually spared since those chemicals are metabolized in the lung.

The following two cases were, in fact, mastocytosis and VIPoma. 

And we got them right in the first round.

Want to know more about Carcinoid Syndrome?


Want to read a real case of Carcinoid Syndrome?


Clinical Board


SS: signs and symptoms; R: right; Tt: resection.

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