[11]</sup> In this patient, the negative results of the rubber series kit obviated the need to repeat the test.<br/><br/>\\r\\n\\r\\nMany known allergens, such as those commonly found in cosmetic products, are not included in patch testing kits. Thus, referral to a specialist for customized patch testing would be useful to confirm the diagnosis in this patient.<br/><br/>\\r\\n\\r\\nAn open application test, also known as a "repeat open application test," is performed after a mildly positive patch test to determine whether the reaction is clinically significant.<sup type=\\\"ref\\\">[13]</sup> The allergen in question is openly and repeatedly applied to a small area of the skin, which is observed for a reaction at regular intervals within the first hour of testing and after 3-4 days.<sup type=\\\"ref\\\">[14]</sup> This test is most appropriate for "leave-on" consumer products suspected to contain low-level contact allergens.<br/><br/>\\r\\n\\r\\nA skin biopsy can exclude other conditions, such as psoriasis. The histologic finding of spongiotic dermatitis is an important clue to the diagnosis of allergic contact dermatitis.<sup type=\\\"ref\\\">[15]</sup> Because the offending agent had been identified in this patient, a skin biopsy was not necessary.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 492331,\n \"questionText\": \"Of the following tests, which would best help to confirm this patient's diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"A 38-Year-Old Radiology Technician With a Blistering, Itchy Rash\"\n },\n {\n \"authors\": \"Melba Estrella, MD; Alan Snyder; John Plante; Dirk M. Elston, MD\",\n \"content\": [],\n \"date\": \"November 15, 2024\",\n \"figures\": [],\n \"markdown\": \"# A 38-Year-Old Radiology Technician With a Blistering, Itchy Rash\\n\\n **Authors:** Melba Estrella, MD; Alan Snyder; John Plante; Dirk M. Elston, MD \\n **Date:** November 15, 2024\\n\\n ## Content\\n\\n \\n\\n ## Figures\\n\\n \\n*Page 6 of 6*\",\n \"pagination\": {\n \"current_page\": 6,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1535601,\n \"choiceText\": \"Natural latex proteins\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535602,\n \"choiceText\": \"Synthetic latex polymers\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535603,\n \"choiceText\": \"Rubber manufacturing accelerators\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535604,\n \"choiceText\": \"Bleached rubber compounds\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Patients can become sensitized to components found in natural rubber (latex) or synthetic rubber; however, they are more likely to become sensitized to the chemicals used in the process of rubber manufacturing, particularly accelerator agents.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 492330,\n \"questionText\": \"Which of the following is most likely to cause allergic contact dermatitis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1535605,\n \"choiceText\": \"Repeat patch testing using a rubber series kit\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535606,\n \"choiceText\": \"Perform patch testing using samples of the patient's underwear\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535607,\n \"choiceText\": \"Perform a repeat open application test\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535608,\n \"choiceText\": \"Perform a punch biopsy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\\r\\nIf allergy remains strongly suspected despite a negative baseline series patch test, a rubber series kit is warranted to avoid false-negative results.<sup type=\\\"ref\\\">[11]</sup> In this patient, the negative results of the rubber series kit obviated the need to repeat the test.<br/><br/>\\r\\n\\r\\nMany known allergens, such as those commonly found in cosmetic products, are not included in patch testing kits. Thus, referral to a specialist for customized patch testing would be useful to confirm the diagnosis in this patient.<br/><br/>\\r\\n\\r\\nAn open application test, also known as a "repeat open application test," is performed after a mildly positive patch test to determine whether the reaction is clinically significant.<sup type=\\\"ref\\\">[13]</sup> The allergen in question is openly and repeatedly applied to a small area of the skin, which is observed for a reaction at regular intervals within the first hour of testing and after 3-4 days.<sup type=\\\"ref\\\">[14]</sup> This test is most appropriate for "leave-on" consumer products suspected to contain low-level contact allergens.<br/><br/>\\r\\n\\r\\nA skin biopsy can exclude other conditions, such as psoriasis. The histologic finding of spongiotic dermatitis is an important clue to the diagnosis of allergic contact dermatitis.<sup type=\\\"ref\\\">[15]</sup> Because the offending agent had been identified in this patient, a skin biopsy was not necessary.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 492331,\n \"questionText\": \"Of the following tests, which would best help to confirm this patient's diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"A 38-Year-Old Radiology Technician With a Blistering, Itchy Rash\"\n }\n]","isConversational":false},"questions":{"kind":"list like","value":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1535597,"choiceText":"Herpes simplex virus infection","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535598,"choiceText":"Atopic dermatitis","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535599,"choiceText":"Plaque psoriasis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535600,"choiceText":"Contact dermatitis","correct":true,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":492329,"questionText":"On the basis of these findings only, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1535601,"choiceText":"Natural latex proteins","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535602,"choiceText":"Synthetic latex polymers","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535603,"choiceText":"Rubber manufacturing accelerators","correct":true,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535604,"choiceText":"Bleached rubber compounds","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Patients can become sensitized to components found in natural rubber (latex) or synthetic rubber; however, they are more likely to become sensitized to the chemicals used in the process of rubber manufacturing, particularly accelerator agents.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":492330,"questionText":"Which of the following is most likely to cause allergic contact dermatitis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1535605,"choiceText":"Repeat patch testing using a rubber series kit","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535606,"choiceText":"Perform patch testing using samples of the patient's underwear","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535607,"choiceText":"Perform a repeat open application test","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1535608,"choiceText":"Perform a punch biopsy","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"\r\nIf allergy remains strongly suspected despite a negative baseline series patch test, a rubber series kit is warranted to avoid false-negative results.<sup type=\"ref\">[11]</sup> In this patient, the negative results of the rubber series kit obviated the need to repeat the test.<br/><br/>\r\n\r\nMany known allergens, such as those commonly found in cosmetic products, are not included in patch testing kits. Thus, referral to a specialist for customized patch testing would be useful to confirm the diagnosis in this patient.<br/><br/>\r\n\r\nAn open application test, also known as a "repeat open application test," is performed after a mildly positive patch test to determine whether the reaction is clinically significant.<sup type=\"ref\">[13]</sup> The allergen in question is openly and repeatedly applied to a small area of the skin, which is observed for a reaction at regular intervals within the first hour of testing and after 3-4 days.<sup type=\"ref\">[14]</sup> This test is most appropriate for "leave-on" consumer products suspected to contain low-level contact allergens.<br/><br/>\r\n\r\nA skin biopsy can exclude other conditions, such as psoriasis. The histologic finding of spongiotic dermatitis is an important clue to the diagnosis of allergic contact dermatitis.<sup type=\"ref\">[15]</sup> Because the offending agent had been identified in this patient, a skin biopsy was not necessary.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":492331,"questionText":"Of the following tests, which would best help to confirm this patient's diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"string":"[\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1535597,\n \"choiceText\": \"Herpes simplex virus infection\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535598,\n \"choiceText\": \"Atopic dermatitis\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535599,\n \"choiceText\": \"Plaque psoriasis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535600,\n \"choiceText\": \"Contact dermatitis\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 492329,\n \"questionText\": \"On the basis of these findings only, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1535601,\n \"choiceText\": \"Natural latex proteins\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535602,\n \"choiceText\": \"Synthetic latex polymers\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535603,\n \"choiceText\": \"Rubber manufacturing accelerators\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535604,\n \"choiceText\": \"Bleached rubber compounds\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Patients can become sensitized to components found in natural rubber (latex) or synthetic rubber; however, they are more likely to become sensitized to the chemicals used in the process of rubber manufacturing, particularly accelerator agents.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 492330,\n \"questionText\": \"Which of the following is most likely to cause allergic contact dermatitis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1535605,\n \"choiceText\": \"Repeat patch testing using a rubber series kit\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535606,\n \"choiceText\": \"Perform patch testing using samples of the patient's underwear\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535607,\n \"choiceText\": \"Perform a repeat open application test\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1535608,\n \"choiceText\": \"Perform a punch biopsy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\\r\\nIf allergy remains strongly suspected despite a negative baseline series patch test, a rubber series kit is warranted to avoid false-negative results.<sup type=\\\"ref\\\">[11]</sup> In this patient, the negative results of the rubber series kit obviated the need to repeat the test.<br/><br/>\\r\\n\\r\\nMany known allergens, such as those commonly found in cosmetic products, are not included in patch testing kits. Thus, referral to a specialist for customized patch testing would be useful to confirm the diagnosis in this patient.<br/><br/>\\r\\n\\r\\nAn open application test, also known as a "repeat open application test," is performed after a mildly positive patch test to determine whether the reaction is clinically significant.<sup type=\\\"ref\\\">[13]</sup> The allergen in question is openly and repeatedly applied to a small area of the skin, which is observed for a reaction at regular intervals within the first hour of testing and after 3-4 days.<sup type=\\\"ref\\\">[14]</sup> This test is most appropriate for "leave-on" consumer products suspected to contain low-level contact allergens.<br/><br/>\\r\\n\\r\\nA skin biopsy can exclude other conditions, such as psoriasis. The histologic finding of spongiotic dermatitis is an important clue to the diagnosis of allergic contact dermatitis.<sup type=\\\"ref\\\">[15]</sup> Because the offending agent had been identified in this patient, a skin biopsy was not necessary.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 492331,\n \"questionText\": \"Of the following tests, which would best help to confirm this patient's diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n]","isConversational":false}}},{"rowIdx":297,"cells":{"article_id":{"kind":"string","value":"842258"},"url":{"kind":"string","value":"/viewarticle/842258"},"article_data":{"kind":"list like","value":[{"authors":"Winston W. Tan, MD; Matthew Tan","content":["Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.","A 63-year-old woman presents with a chronic cough. She was in her usual state of health until 3 months ago, when she developed a dry cough with fever. She was initially treated with antibiotics for 2 weeks. The cough improved, and the fever resolved. However, the dry cough returned.","The patient reports recent several instances of hemoptysis, as well as a 5-lb weight loss that she attributes to her recent diet change and exercise. She also describes chest pain, shortness of breath, dyspnea, and significant lower back pain.","Her medical history is significant for hypertension and diabetes. Her family history includes a father who had congestive heart failure at age 73 years. The patient gets her eyes checked regularly. She has never seen a pulmonary specialist. She reports aches and pains that vary, depending on how much physical activity she gets. She has had a hysterectomy. She is married and denies smoking, although she reports a history of continued secondhand smoke exposure."],"date":"October 16, 2020","figures":[],"markdown":"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\n\n **Authors:** Winston W. Tan, MD; Matthew Tan \n **Date:** October 16, 2020\n\n ## Content\n\n Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.\nA 63-year-old woman presents with a chronic cough. She was in her usual state of health until 3 months ago, when she developed a dry cough with fever. She was initially treated with antibiotics for 2 weeks. The cough improved, and the fever resolved. However, the dry cough returned.\nThe patient reports recent several instances of hemoptysis, as well as a 5-lb weight loss that she attributes to her recent diet change and exercise. She also describes chest pain, shortness of breath, dyspnea, and significant lower back pain.\nHer medical history is significant for hypertension and diabetes. Her family history includes a father who had congestive heart failure at age 73 years. The patient gets her eyes checked regularly. She has never seen a pulmonary specialist. She reports aches and pains that vary, depending on how much physical activity she gets. She has had a hysterectomy. She is married and denies smoking, although she reports a history of continued secondhand smoke exposure.\n\n ## Figures\n\n \n*Page 1 of 6*","pagination":{"current_page":1,"total_pages":6},"questionnaire":[],"title":"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old"},{"authors":"Winston W. Tan, MD; Matthew Tan","content":["Physical examination reveals the following:","Blood pressure: 124/58 mm Hg","Temperature: 98.3°F (36.8°C)","Heart rate: 85 beats/min","Examination of her neck reveals enlarged supraclavicular lymph nodes. Examination of her breasts reveals no distinct nodules, lumps, discharge, skin retraction, or axillary adenopathy. Her abdomen is soft, benign, and nontender. Neurologically, cranial nerves II through XII are grossly intact.","Upon evaluation of the lungs, wheezing and atelectasis are observed. Increased work of breathing is also noted. A chest radiograph is subsequently ordered."],"date":"October 16, 2020","figures":[],"markdown":"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\n\n **Authors:** Winston W. Tan, MD; Matthew Tan \n **Date:** October 16, 2020\n\n ## Content\n\n Physical examination reveals the following:\nBlood pressure: 124/58 mm Hg\nTemperature: 98.3°F (36.8°C)\nHeart rate: 85 beats/min\nExamination of her neck reveals enlarged supraclavicular lymph nodes. Examination of her breasts reveals no distinct nodules, lumps, discharge, skin retraction, or axillary adenopathy. Her abdomen is soft, benign, and nontender. Neurologically, cranial nerves II through XII are grossly intact.\nUpon evaluation of the lungs, wheezing and atelectasis are observed. Increased work of breathing is also noted. A chest radiograph is subsequently ordered.\n\n ## Figures\n\n \n*Page 2 of 6*","pagination":{"current_page":2,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831357,"choiceText":"Sarcoidosis","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831359,"choiceText":"Lung cancer","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831361,"choiceText":"Tuberculosis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831363,"choiceText":"Pneumonia \r\n","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261411,"questionText":"Based only on these findings, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old"},{"authors":"Winston W. Tan, MD; Matthew Tan","content":["Lung cancer is often insidious, failing to produce clear symptoms until advanced disease. A high index of suspicion is required to properly identify this disease in most patients. In this case, weight loss, hemoptysis, and a history of secondhand smoke exposure, along with a low-grade fever and irregularities upon lung evaluation, warranted an investigation for lung cancer. Subsequently, CT revealed a 1.3-cm left upper lobe complex nodule (Figure 1).","Figure 1.","The patient underwent a left upper lobectomy with mediastinal lymph node dissection for a 1.5-cm poorly differentiated squamous cancer of lung, with 1 (station 5) of 18 lymph nodes positive with a microscopic focus of cancer. She was subsequently treated with adjuvant chemoradiation therapy, consisting of cisplatin and docetaxel concurrent with radiation. However, chemotherapy was stopped after a few doses owing to complications.","The patient later developed a seizure and was hospitalized; MRI of the brain was negative for metastatic disease but suggested possible temporal lobe inflammation. Her cerebrospinal fluid was positive for herpes. She was started on phenytoin and valacyclovir.","She completed radiation therapy to 6120 cGy. Additional planned chemotherapy was delayed owing to the patient's debility. She also experienced an outbreak of shingles. Serial follow-up every 4 months showed that disease was in complete remission, with a stable postradiation residual scar in the left lung.","Figure 2.","Figure 3.","Six years later, CT revealed a new enhancing mass in the medial right upper lobe (adjacent to the mediastinum) that was suspicious for metastatic or new primary lung cancer (Figure 2). A brain scan was negative for metastases. PET revealed uptake in the expected area and indeterminate uptake in a right hilar node (Figure 3), but was otherwise negative. Pulmonary function tests revealed showed an FEV1 of 1.45 L, or 65% of predicted. The diffusing capacity of the lung for carbon monoxide (DLCO) was 42%. Saturation was normal at rest but decreased to 92% with exercise.","Endobronchial ultrasonography did not reveal any specific abnormality. The mucosa was friable. A right hilar lymph node was sampled, but no lymphoid elements were obtained. Nothing specific for the tumor area was seen.","Figure 4.","A CT-guided biopsy was nondiagnostic. Surgical exploration yielded a small cell carcinoma that was unresectable owing to mediastinal invasion and bleeding (Figure 4). The patient started palliative chemotherapy with carboplatin/etoposide, with etoposide given orally on days 2 and 3. She completed four cycles of this chemotherapy and tolerated chemotherapy well overall.","Follow-up CT showed minimal residual density in the area of the prior lesion. As a result of excellent response, she was referred for proton therapy, because standard radiation was not feasible owing to prior dosing.","Induction chemotherapy was followed by consolidation radiation. The patient subsequently underwent proton radiation to the residual chest mass. She experienced a seizure; she was dehydrated, and was started on anticonvulsant and became stable. MRI of the brain revealed an area of right anterior temporal encephalomalacia. She is doing well currently and is under active surveillance for her cancer."],"date":"October 16, 2020","figures":[{"caption":"Figure 1.","image_url":"https://img.medscapestatic.com/article/842/258/842258-Thumb1a.png"},{"caption":"Figure 2.","image_url":"https://img.medscapestatic.com/article/842/258/842258-Thumb2a.png"},{"caption":"Figure 3.","image_url":"https://img.medscapestatic.com/article/842/258/842258-Thumb3a.png"},{"caption":"Figure 4.","image_url":"https://img.medscapestatic.com/article/842/258/842258-Thumb4a.png"}],"markdown":"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\n\n **Authors:** Winston W. Tan, MD; Matthew Tan \n **Date:** October 16, 2020\n\n ## Content\n\n Lung cancer is often insidious, failing to produce clear symptoms until advanced disease. A high index of suspicion is required to properly identify this disease in most patients. In this case, weight loss, hemoptysis, and a history of secondhand smoke exposure, along with a low-grade fever and irregularities upon lung evaluation, warranted an investigation for lung cancer. Subsequently, CT revealed a 1.3-cm left upper lobe complex nodule (Figure 1).\nFigure 1.\nThe patient underwent a left upper lobectomy with mediastinal lymph node dissection for a 1.5-cm poorly differentiated squamous cancer of lung, with 1 (station 5) of 18 lymph nodes positive with a microscopic focus of cancer. She was subsequently treated with adjuvant chemoradiation therapy, consisting of cisplatin and docetaxel concurrent with radiation. However, chemotherapy was stopped after a few doses owing to complications.\nThe patient later developed a seizure and was hospitalized; MRI of the brain was negative for metastatic disease but suggested possible temporal lobe inflammation. Her cerebrospinal fluid was positive for herpes. She was started on phenytoin and valacyclovir.\nShe completed radiation therapy to 6120 cGy. Additional planned chemotherapy was delayed owing to the patient's debility. She also experienced an outbreak of shingles. Serial follow-up every 4 months showed that disease was in complete remission, with a stable postradiation residual scar in the left lung.\nFigure 2.\nFigure 3.\nSix years later, CT revealed a new enhancing mass in the medial right upper lobe (adjacent to the mediastinum) that was suspicious for metastatic or new primary lung cancer (Figure 2). A brain scan was negative for metastases. PET revealed uptake in the expected area and indeterminate uptake in a right hilar node (Figure 3), but was otherwise negative. Pulmonary function tests revealed showed an FEV1 of 1.45 L, or 65% of predicted. The diffusing capacity of the lung for carbon monoxide (DLCO) was 42%. Saturation was normal at rest but decreased to 92% with exercise.\nEndobronchial ultrasonography did not reveal any specific abnormality. The mucosa was friable. A right hilar lymph node was sampled, but no lymphoid elements were obtained. Nothing specific for the tumor area was seen.\nFigure 4.\nA CT-guided biopsy was nondiagnostic. Surgical exploration yielded a small cell carcinoma that was unresectable owing to mediastinal invasion and bleeding (Figure 4). The patient started palliative chemotherapy with carboplatin/etoposide, with etoposide given orally on days 2 and 3. She completed four cycles of this chemotherapy and tolerated chemotherapy well overall.\nFollow-up CT showed minimal residual density in the area of the prior lesion. As a result of excellent response, she was referred for proton therapy, because standard radiation was not feasible owing to prior dosing.\nInduction chemotherapy was followed by consolidation radiation. The patient subsequently underwent proton radiation to the residual chest mass. She experienced a seizure; she was dehydrated, and was started on anticonvulsant and became stable. MRI of the brain revealed an area of right anterior temporal encephalomalacia. She is doing well currently and is under active surveillance for her cancer.\n\n ## Figures\n\n **Figure 1.** \n \n\n**Figure 2.** \n \n\n**Figure 3.** \n \n\n**Figure 4.** \n \n\n\n*Page 3 of 6*","pagination":{"current_page":3,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831357,"choiceText":"Sarcoidosis","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831359,"choiceText":"Lung cancer","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831361,"choiceText":"Tuberculosis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831363,"choiceText":"Pneumonia \r\n","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261411,"questionText":"Based only on these findings, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old"},{"authors":"Winston W. Tan, MD; Matthew Tan","content":["Non-small cell lung cancer accounts for approximately 85% of all lung cancers. Histologically, it is divided into adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Patients with non-small cell lung cancer require a complete staging work-up to evaluate the extent of disease because stage plays a major role in determining the choice of treatment.[1]","The patient in this case has the typical presentation of chronic cough. Typically, a cough that is initially thought to be an infection is noted. A chronic cough without improvement of symptoms despite treatment for infection should prompt further evaluation for potential lung mass. CT of the chest is often used as a diagnostic tool to clarify the suspicion of a lung mass.[2]","Because of the importance of stage in the therapeutic decision-making process, all patients must undergo proper staging of disease. A complete staging work-up should be performed to evaluate the extent of disease. In the United States, the standard staging work-up includes the following:","CT of the chest and upper abdomen","Complete blood count with differential","Serum chemistry studies, including creatinine, electrolytes, and calcium","Alkaline phosphate","Aspartate aminotransferase","Pulmonary function testing","Mediastinoscopy (if surgical resection is considered)","The information obtained from these tests guides additional testing (eg, imaging studies). Invasive staging procedures (eg, mediastinoscopy, mediastinotomy) may be required to assess mediastinal lymph nodes in patients who may undergo surgical resection. PET may be useful in detecting affected nodes, which may influence decisions about operability.","Paraneoplastic syndromes are more likely to occur in small cell lung cancer than in non-small cell lung cancer. Patients are at risk for the following:","Cushing syndrome","Lambert-Eaton myasthenic syndrome (Onset of proximal lower-extremity weakness is gradual; proximal upper-extremity weakness is usually less noticeable; the syndrome may be worse in the morning and improve during the day; although extraocular muscle involvement is uncommon, ptosis is often found)","Hypercalcemia (usually occurs with squamous cell carcinoma)","Syndrome of inappropriate antidiuretic hormone secretion","Enlargement of the extremities and painful, swollen joints (hypertrophic osteoarthropathy)"],"date":"October 16, 2020","figures":[],"markdown":"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\n\n **Authors:** Winston W. Tan, MD; Matthew Tan \n **Date:** October 16, 2020\n\n ## Content\n\n Non-small cell lung cancer accounts for approximately 85% of all lung cancers. Histologically, it is divided into adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Patients with non-small cell lung cancer require a complete staging work-up to evaluate the extent of disease because stage plays a major role in determining the choice of treatment.[1]\nThe patient in this case has the typical presentation of chronic cough. Typically, a cough that is initially thought to be an infection is noted. A chronic cough without improvement of symptoms despite treatment for infection should prompt further evaluation for potential lung mass. CT of the chest is often used as a diagnostic tool to clarify the suspicion of a lung mass.[2]\nBecause of the importance of stage in the therapeutic decision-making process, all patients must undergo proper staging of disease. A complete staging work-up should be performed to evaluate the extent of disease. In the United States, the standard staging work-up includes the following:\nCT of the chest and upper abdomen\nComplete blood count with differential\nSerum chemistry studies, including creatinine, electrolytes, and calcium\nAlkaline phosphate\nAspartate aminotransferase\nPulmonary function testing\nMediastinoscopy (if surgical resection is considered)\nThe information obtained from these tests guides additional testing (eg, imaging studies). Invasive staging procedures (eg, mediastinoscopy, mediastinotomy) may be required to assess mediastinal lymph nodes in patients who may undergo surgical resection. PET may be useful in detecting affected nodes, which may influence decisions about operability.\nParaneoplastic syndromes are more likely to occur in small cell lung cancer than in non-small cell lung cancer. Patients are at risk for the following:\nCushing syndrome\nLambert-Eaton myasthenic syndrome (Onset of proximal lower-extremity weakness is gradual; proximal upper-extremity weakness is usually less noticeable; the syndrome may be worse in the morning and improve during the day; although extraocular muscle involvement is uncommon, ptosis is often found)\nHypercalcemia (usually occurs with squamous cell carcinoma)\nSyndrome of inappropriate antidiuretic hormone secretion\nEnlargement of the extremities and painful, swollen joints (hypertrophic osteoarthropathy)\n\n ## Figures\n\n \n*Page 4 of 6*","pagination":{"current_page":4,"total_pages":6},"questionnaire":[],"title":"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old"},{"authors":"Winston W. Tan, MD; Matthew Tan","content":["The standard treatment for stage I and II disease is surgical resection. In stage IIIA, chemotherapy is indicated, as is surgical resection in selected patients. Standard treatment of stage IIIb is chemoradiation. Stage IV requires cisplatin-based chemotherapy or surgical resection if a solitary metastatic lesion with resectable primary tumor is present.[3,4,5]","This patient underwent resection of the cancer. Owing to her residual disease and because her lymph nodes were positive, she was treated with chemoradiation. Surgical resection is the primary modality of treatment for early stage non-small cell lung cancer.[6]","Close surveillance of patients with cancer should be the standard after completion of therapy. This patient had a contralateral hilar recurrence 6 years later. When a patient has a recurrence, it must be determined whether it is the same cancer or another primary cancer. This patient had another primary cancer, specifically small cell cancer of the lung. Biopsy must be done of a new recurrence, because it could be an entirely different cancer.","Approximately 60%-70% of patients with small cell lung cancer have clinically disseminated or extensive disease at presentation. Extensive-stage small cell lung cancer is incurable. When given combination chemotherapy, patients with extensive-stage disease have a complete response rate of more than 20% and a median survival longer than 7 months; however, only 2% are alive at 5 years.","For individuals with limited-stage disease that is treated with combination chemotherapy plus chest radiation, a complete response rate of 80% and survival of 17 months have been reported; 12%-15% of patients are alive at 5 years.[1]","Recommendations from the National Comprehensive Cancer Network (NCCN) regarding cancer surveillance in survivors of non-small cell lung cancer include the following:","History and physical examination, and chest CT with or without contrast, every 6-12 months for 2 years, then history and physical examination and noncontrast chest CT annually","Assessment of smoking status at each visit, with counseling and referral for smoking cessation as needed","Other NCCN recommendations for long-term follow-up care include the following:","Immunization: Annual influenza vaccination, pneumococcal vaccination with revaccination as appropriate, herpes zoster vaccination","Counseling regarding health promotion and wellness (eg, regular physical activity, healthy diet)","Routine health monitoring","Several important points should be remembered:","Persistent cough despite treatment should prompt further diagnostic testing for lung mass.","Nonsmokers can develop lung cancer.","Neurologic symptoms in patients with lung cancer do not always mean brain metastasis. Although brain metastasis should be ruled out, other causes could be found, such as encephalomalacia.","Biopsy of recurrent cancer should be redone, especially if the time to recurrence is more than a few years. A separate cancer can be found in a patient previously cured of their cancer.","Several factors may increase the likelihood of a primary cancer resulting in a secondary cancer. A \"field effect\" is noted in certain types of cancers, particularly in the areas of respiratory tract. In smokers, this is especially true in such areas as the head and neck, throat, laryngeal, esophageal area, and tongue. Because the body's immune system is vulnerable to the development of the first cancer, it may be more susceptible to the development of a second cancer."],"date":"October 16, 2020","figures":[],"markdown":"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\n\n **Authors:** Winston W. Tan, MD; Matthew Tan \n **Date:** October 16, 2020\n\n ## Content\n\n The standard treatment for stage I and II disease is surgical resection. In stage IIIA, chemotherapy is indicated, as is surgical resection in selected patients. Standard treatment of stage IIIb is chemoradiation. Stage IV requires cisplatin-based chemotherapy or surgical resection if a solitary metastatic lesion with resectable primary tumor is present.[3,4,5]\nThis patient underwent resection of the cancer. Owing to her residual disease and because her lymph nodes were positive, she was treated with chemoradiation. Surgical resection is the primary modality of treatment for early stage non-small cell lung cancer.[6]\nClose surveillance of patients with cancer should be the standard after completion of therapy. This patient had a contralateral hilar recurrence 6 years later. When a patient has a recurrence, it must be determined whether it is the same cancer or another primary cancer. This patient had another primary cancer, specifically small cell cancer of the lung. Biopsy must be done of a new recurrence, because it could be an entirely different cancer.\nApproximately 60%-70% of patients with small cell lung cancer have clinically disseminated or extensive disease at presentation. Extensive-stage small cell lung cancer is incurable. When given combination chemotherapy, patients with extensive-stage disease have a complete response rate of more than 20% and a median survival longer than 7 months; however, only 2% are alive at 5 years.\nFor individuals with limited-stage disease that is treated with combination chemotherapy plus chest radiation, a complete response rate of 80% and survival of 17 months have been reported; 12%-15% of patients are alive at 5 years.[1]\nRecommendations from the National Comprehensive Cancer Network (NCCN) regarding cancer surveillance in survivors of non-small cell lung cancer include the following:\nHistory and physical examination, and chest CT with or without contrast, every 6-12 months for 2 years, then history and physical examination and noncontrast chest CT annually\nAssessment of smoking status at each visit, with counseling and referral for smoking cessation as needed\nOther NCCN recommendations for long-term follow-up care include the following:\nImmunization: Annual influenza vaccination, pneumococcal vaccination with revaccination as appropriate, herpes zoster vaccination\nCounseling regarding health promotion and wellness (eg, regular physical activity, healthy diet)\nRoutine health monitoring\nSeveral important points should be remembered:\nPersistent cough despite treatment should prompt further diagnostic testing for lung mass.\nNonsmokers can develop lung cancer.\nNeurologic symptoms in patients with lung cancer do not always mean brain metastasis. Although brain metastasis should be ruled out, other causes could be found, such as encephalomalacia.\nBiopsy of recurrent cancer should be redone, especially if the time to recurrence is more than a few years. A separate cancer can be found in a patient previously cured of their cancer.\nSeveral factors may increase the likelihood of a primary cancer resulting in a secondary cancer. A \"field effect\" is noted in certain types of cancers, particularly in the areas of respiratory tract. In smokers, this is especially true in such areas as the head and neck, throat, laryngeal, esophageal area, and tongue. Because the body's immune system is vulnerable to the development of the first cancer, it may be more susceptible to the development of a second cancer.\n\n ## Figures\n\n \n*Page 5 of 6*","pagination":{"current_page":5,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831365,"choiceText":"Adenocarcinoma","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831367,"choiceText":"Squamous cell carcinoma","correct":true,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831369,"choiceText":"Large-cell carcinoma","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831371,"choiceText":"None of the above\r\n","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"The most common metabolic abnormality associated with non-small cell lung cancer is hypercalcemia, which usually occurs with squamous cell carcinoma and results from secretion of parathyroid hormone-related peptide by the tumor. This can be distinguished from hyperparathyroidism by confirmation of normal serum parathyroid hormone levels.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261413,"questionText":"Which of the following is most commonly associated with hypercalcemia in patients with non-small cell lung cancer?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831373,"choiceText":"Smoke exposure","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831375,"choiceText":"Family history","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831377,"choiceText":"Poor diet","correct":true,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831379,"choiceText":"Chemical exposure","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Smoking is the most well-recognized risk factor for lung cancer. Even secondhand exposure carries a significant risk. In addition, exposure to certain gases (eg, radon), asbestos, and other chemicals may increase the risk for lung cancer. Likewise, a family history of lung cancer increases risk for the disease.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261415,"questionText":"Which of the following is <i>not</i> considered a primary risk factor for lung cancer?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old"},{"authors":"Winston W. Tan, MD; Matthew Tan","content":[],"date":"October 16, 2020","figures":[],"markdown":"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\n\n **Authors:** Winston W. Tan, MD; Matthew Tan \n **Date:** October 16, 2020\n\n ## Content\n\n \n\n ## Figures\n\n \n*Page 6 of 6*","pagination":{"current_page":6,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831365,"choiceText":"Adenocarcinoma","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831367,"choiceText":"Squamous cell carcinoma","correct":true,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831369,"choiceText":"Large-cell carcinoma","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831371,"choiceText":"None of the above\r\n","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"The most common metabolic abnormality associated with non-small cell lung cancer is hypercalcemia, which usually occurs with squamous cell carcinoma and results from secretion of parathyroid hormone-related peptide by the tumor. This can be distinguished from hyperparathyroidism by confirmation of normal serum parathyroid hormone levels.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261413,"questionText":"Which of the following is most commonly associated with hypercalcemia in patients with non-small cell lung cancer?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831373,"choiceText":"Smoke exposure","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831375,"choiceText":"Family history","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831377,"choiceText":"Poor diet","correct":true,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831379,"choiceText":"Chemical exposure","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Smoking is the most well-recognized risk factor for lung cancer. Even secondhand exposure carries a significant risk. In addition, exposure to certain gases (eg, radon), asbestos, and other chemicals may increase the risk for lung cancer. Likewise, a family history of lung cancer increases risk for the disease.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261415,"questionText":"Which of the following is <i>not</i> considered a primary risk factor for lung cancer?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old"}],"string":"[\n {\n \"authors\": \"Winston W. Tan, MD; Matthew Tan\",\n \"content\": [\n \"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.\",\n \"A 63-year-old woman presents with a chronic cough. She was in her usual state of health until 3 months ago, when she developed a dry cough with fever. She was initially treated with antibiotics for 2 weeks. The cough improved, and the fever resolved. However, the dry cough returned.\",\n \"The patient reports recent several instances of hemoptysis, as well as a 5-lb weight loss that she attributes to her recent diet change and exercise. She also describes chest pain, shortness of breath, dyspnea, and significant lower back pain.\",\n \"Her medical history is significant for hypertension and diabetes. Her family history includes a father who had congestive heart failure at age 73 years. The patient gets her eyes checked regularly. She has never seen a pulmonary specialist. She reports aches and pains that vary, depending on how much physical activity she gets. She has had a hysterectomy. She is married and denies smoking, although she reports a history of continued secondhand smoke exposure.\"\n ],\n \"date\": \"October 16, 2020\",\n \"figures\": [],\n \"markdown\": \"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\\n\\n **Authors:** Winston W. Tan, MD; Matthew Tan \\n **Date:** October 16, 2020\\n\\n ## Content\\n\\n Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.\\nA 63-year-old woman presents with a chronic cough. She was in her usual state of health until 3 months ago, when she developed a dry cough with fever. She was initially treated with antibiotics for 2 weeks. The cough improved, and the fever resolved. However, the dry cough returned.\\nThe patient reports recent several instances of hemoptysis, as well as a 5-lb weight loss that she attributes to her recent diet change and exercise. She also describes chest pain, shortness of breath, dyspnea, and significant lower back pain.\\nHer medical history is significant for hypertension and diabetes. Her family history includes a father who had congestive heart failure at age 73 years. The patient gets her eyes checked regularly. She has never seen a pulmonary specialist. She reports aches and pains that vary, depending on how much physical activity she gets. She has had a hysterectomy. She is married and denies smoking, although she reports a history of continued secondhand smoke exposure.\\n\\n ## Figures\\n\\n \\n*Page 1 of 6*\",\n \"pagination\": {\n \"current_page\": 1,\n \"total_pages\": 6\n },\n \"questionnaire\": [],\n \"title\": \"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\"\n },\n {\n \"authors\": \"Winston W. Tan, MD; Matthew Tan\",\n \"content\": [\n \"Physical examination reveals the following:\",\n \"Blood pressure: 124/58 mm Hg\",\n \"Temperature: 98.3°F (36.8°C)\",\n \"Heart rate: 85 beats/min\",\n \"Examination of her neck reveals enlarged supraclavicular lymph nodes. Examination of her breasts reveals no distinct nodules, lumps, discharge, skin retraction, or axillary adenopathy. Her abdomen is soft, benign, and nontender. Neurologically, cranial nerves II through XII are grossly intact.\",\n \"Upon evaluation of the lungs, wheezing and atelectasis are observed. Increased work of breathing is also noted. A chest radiograph is subsequently ordered.\"\n ],\n \"date\": \"October 16, 2020\",\n \"figures\": [],\n \"markdown\": \"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\\n\\n **Authors:** Winston W. Tan, MD; Matthew Tan \\n **Date:** October 16, 2020\\n\\n ## Content\\n\\n Physical examination reveals the following:\\nBlood pressure: 124/58 mm Hg\\nTemperature: 98.3°F (36.8°C)\\nHeart rate: 85 beats/min\\nExamination of her neck reveals enlarged supraclavicular lymph nodes. Examination of her breasts reveals no distinct nodules, lumps, discharge, skin retraction, or axillary adenopathy. Her abdomen is soft, benign, and nontender. Neurologically, cranial nerves II through XII are grossly intact.\\nUpon evaluation of the lungs, wheezing and atelectasis are observed. Increased work of breathing is also noted. A chest radiograph is subsequently ordered.\\n\\n ## Figures\\n\\n \\n*Page 2 of 6*\",\n \"pagination\": {\n \"current_page\": 2,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831357,\n \"choiceText\": \"Sarcoidosis\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831359,\n \"choiceText\": \"Lung cancer\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831361,\n \"choiceText\": \"Tuberculosis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831363,\n \"choiceText\": \"Pneumonia \\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261411,\n \"questionText\": \"Based only on these findings, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\"\n },\n {\n \"authors\": \"Winston W. Tan, MD; Matthew Tan\",\n \"content\": [\n \"Lung cancer is often insidious, failing to produce clear symptoms until advanced disease. A high index of suspicion is required to properly identify this disease in most patients. In this case, weight loss, hemoptysis, and a history of secondhand smoke exposure, along with a low-grade fever and irregularities upon lung evaluation, warranted an investigation for lung cancer. Subsequently, CT revealed a 1.3-cm left upper lobe complex nodule (Figure 1).\",\n \"Figure 1.\",\n \"The patient underwent a left upper lobectomy with mediastinal lymph node dissection for a 1.5-cm poorly differentiated squamous cancer of lung, with 1 (station 5) of 18 lymph nodes positive with a microscopic focus of cancer. She was subsequently treated with adjuvant chemoradiation therapy, consisting of cisplatin and docetaxel concurrent with radiation. However, chemotherapy was stopped after a few doses owing to complications.\",\n \"The patient later developed a seizure and was hospitalized; MRI of the brain was negative for metastatic disease but suggested possible temporal lobe inflammation. Her cerebrospinal fluid was positive for herpes. She was started on phenytoin and valacyclovir.\",\n \"She completed radiation therapy to 6120 cGy. Additional planned chemotherapy was delayed owing to the patient's debility. She also experienced an outbreak of shingles. Serial follow-up every 4 months showed that disease was in complete remission, with a stable postradiation residual scar in the left lung.\",\n \"Figure 2.\",\n \"Figure 3.\",\n \"Six years later, CT revealed a new enhancing mass in the medial right upper lobe (adjacent to the mediastinum) that was suspicious for metastatic or new primary lung cancer (Figure 2). A brain scan was negative for metastases. PET revealed uptake in the expected area and indeterminate uptake in a right hilar node (Figure 3), but was otherwise negative. Pulmonary function tests revealed showed an FEV1 of 1.45 L, or 65% of predicted. The diffusing capacity of the lung for carbon monoxide (DLCO) was 42%. Saturation was normal at rest but decreased to 92% with exercise.\",\n \"Endobronchial ultrasonography did not reveal any specific abnormality. The mucosa was friable. A right hilar lymph node was sampled, but no lymphoid elements were obtained. Nothing specific for the tumor area was seen.\",\n \"Figure 4.\",\n \"A CT-guided biopsy was nondiagnostic. Surgical exploration yielded a small cell carcinoma that was unresectable owing to mediastinal invasion and bleeding (Figure 4). The patient started palliative chemotherapy with carboplatin/etoposide, with etoposide given orally on days 2 and 3. She completed four cycles of this chemotherapy and tolerated chemotherapy well overall.\",\n \"Follow-up CT showed minimal residual density in the area of the prior lesion. As a result of excellent response, she was referred for proton therapy, because standard radiation was not feasible owing to prior dosing.\",\n \"Induction chemotherapy was followed by consolidation radiation. The patient subsequently underwent proton radiation to the residual chest mass. She experienced a seizure; she was dehydrated, and was started on anticonvulsant and became stable. MRI of the brain revealed an area of right anterior temporal encephalomalacia. She is doing well currently and is under active surveillance for her cancer.\"\n ],\n \"date\": \"October 16, 2020\",\n \"figures\": [\n {\n \"caption\": \"Figure 1.\",\n \"image_url\": \"https://img.medscapestatic.com/article/842/258/842258-Thumb1a.png\"\n },\n {\n \"caption\": \"Figure 2.\",\n \"image_url\": \"https://img.medscapestatic.com/article/842/258/842258-Thumb2a.png\"\n },\n {\n \"caption\": \"Figure 3.\",\n \"image_url\": \"https://img.medscapestatic.com/article/842/258/842258-Thumb3a.png\"\n },\n {\n \"caption\": \"Figure 4.\",\n \"image_url\": \"https://img.medscapestatic.com/article/842/258/842258-Thumb4a.png\"\n }\n ],\n \"markdown\": \"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\\n\\n **Authors:** Winston W. Tan, MD; Matthew Tan \\n **Date:** October 16, 2020\\n\\n ## Content\\n\\n Lung cancer is often insidious, failing to produce clear symptoms until advanced disease. A high index of suspicion is required to properly identify this disease in most patients. In this case, weight loss, hemoptysis, and a history of secondhand smoke exposure, along with a low-grade fever and irregularities upon lung evaluation, warranted an investigation for lung cancer. Subsequently, CT revealed a 1.3-cm left upper lobe complex nodule (Figure 1).\\nFigure 1.\\nThe patient underwent a left upper lobectomy with mediastinal lymph node dissection for a 1.5-cm poorly differentiated squamous cancer of lung, with 1 (station 5) of 18 lymph nodes positive with a microscopic focus of cancer. She was subsequently treated with adjuvant chemoradiation therapy, consisting of cisplatin and docetaxel concurrent with radiation. However, chemotherapy was stopped after a few doses owing to complications.\\nThe patient later developed a seizure and was hospitalized; MRI of the brain was negative for metastatic disease but suggested possible temporal lobe inflammation. Her cerebrospinal fluid was positive for herpes. She was started on phenytoin and valacyclovir.\\nShe completed radiation therapy to 6120 cGy. Additional planned chemotherapy was delayed owing to the patient's debility. She also experienced an outbreak of shingles. Serial follow-up every 4 months showed that disease was in complete remission, with a stable postradiation residual scar in the left lung.\\nFigure 2.\\nFigure 3.\\nSix years later, CT revealed a new enhancing mass in the medial right upper lobe (adjacent to the mediastinum) that was suspicious for metastatic or new primary lung cancer (Figure 2). A brain scan was negative for metastases. PET revealed uptake in the expected area and indeterminate uptake in a right hilar node (Figure 3), but was otherwise negative. Pulmonary function tests revealed showed an FEV1 of 1.45 L, or 65% of predicted. The diffusing capacity of the lung for carbon monoxide (DLCO) was 42%. Saturation was normal at rest but decreased to 92% with exercise.\\nEndobronchial ultrasonography did not reveal any specific abnormality. The mucosa was friable. A right hilar lymph node was sampled, but no lymphoid elements were obtained. Nothing specific for the tumor area was seen.\\nFigure 4.\\nA CT-guided biopsy was nondiagnostic. Surgical exploration yielded a small cell carcinoma that was unresectable owing to mediastinal invasion and bleeding (Figure 4). The patient started palliative chemotherapy with carboplatin/etoposide, with etoposide given orally on days 2 and 3. She completed four cycles of this chemotherapy and tolerated chemotherapy well overall.\\nFollow-up CT showed minimal residual density in the area of the prior lesion. As a result of excellent response, she was referred for proton therapy, because standard radiation was not feasible owing to prior dosing.\\nInduction chemotherapy was followed by consolidation radiation. The patient subsequently underwent proton radiation to the residual chest mass. She experienced a seizure; she was dehydrated, and was started on anticonvulsant and became stable. MRI of the brain revealed an area of right anterior temporal encephalomalacia. She is doing well currently and is under active surveillance for her cancer.\\n\\n ## Figures\\n\\n **Figure 1.** \\n \\n\\n**Figure 2.** \\n \\n\\n**Figure 3.** \\n \\n\\n**Figure 4.** \\n \\n\\n\\n*Page 3 of 6*\",\n \"pagination\": {\n \"current_page\": 3,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831357,\n \"choiceText\": \"Sarcoidosis\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831359,\n \"choiceText\": \"Lung cancer\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831361,\n \"choiceText\": \"Tuberculosis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831363,\n \"choiceText\": \"Pneumonia \\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261411,\n \"questionText\": \"Based only on these findings, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\"\n },\n {\n \"authors\": \"Winston W. Tan, MD; Matthew Tan\",\n \"content\": [\n \"Non-small cell lung cancer accounts for approximately 85% of all lung cancers. Histologically, it is divided into adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Patients with non-small cell lung cancer require a complete staging work-up to evaluate the extent of disease because stage plays a major role in determining the choice of treatment.[1]\",\n \"The patient in this case has the typical presentation of chronic cough. Typically, a cough that is initially thought to be an infection is noted. A chronic cough without improvement of symptoms despite treatment for infection should prompt further evaluation for potential lung mass. CT of the chest is often used as a diagnostic tool to clarify the suspicion of a lung mass.[2]\",\n \"Because of the importance of stage in the therapeutic decision-making process, all patients must undergo proper staging of disease. A complete staging work-up should be performed to evaluate the extent of disease. In the United States, the standard staging work-up includes the following:\",\n \"CT of the chest and upper abdomen\",\n \"Complete blood count with differential\",\n \"Serum chemistry studies, including creatinine, electrolytes, and calcium\",\n \"Alkaline phosphate\",\n \"Aspartate aminotransferase\",\n \"Pulmonary function testing\",\n \"Mediastinoscopy (if surgical resection is considered)\",\n \"The information obtained from these tests guides additional testing (eg, imaging studies). Invasive staging procedures (eg, mediastinoscopy, mediastinotomy) may be required to assess mediastinal lymph nodes in patients who may undergo surgical resection. PET may be useful in detecting affected nodes, which may influence decisions about operability.\",\n \"Paraneoplastic syndromes are more likely to occur in small cell lung cancer than in non-small cell lung cancer. Patients are at risk for the following:\",\n \"Cushing syndrome\",\n \"Lambert-Eaton myasthenic syndrome (Onset of proximal lower-extremity weakness is gradual; proximal upper-extremity weakness is usually less noticeable; the syndrome may be worse in the morning and improve during the day; although extraocular muscle involvement is uncommon, ptosis is often found)\",\n \"Hypercalcemia (usually occurs with squamous cell carcinoma)\",\n \"Syndrome of inappropriate antidiuretic hormone secretion\",\n \"Enlargement of the extremities and painful, swollen joints (hypertrophic osteoarthropathy)\"\n ],\n \"date\": \"October 16, 2020\",\n \"figures\": [],\n \"markdown\": \"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\\n\\n **Authors:** Winston W. Tan, MD; Matthew Tan \\n **Date:** October 16, 2020\\n\\n ## Content\\n\\n Non-small cell lung cancer accounts for approximately 85% of all lung cancers. Histologically, it is divided into adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Patients with non-small cell lung cancer require a complete staging work-up to evaluate the extent of disease because stage plays a major role in determining the choice of treatment.[1]\\nThe patient in this case has the typical presentation of chronic cough. Typically, a cough that is initially thought to be an infection is noted. A chronic cough without improvement of symptoms despite treatment for infection should prompt further evaluation for potential lung mass. CT of the chest is often used as a diagnostic tool to clarify the suspicion of a lung mass.[2]\\nBecause of the importance of stage in the therapeutic decision-making process, all patients must undergo proper staging of disease. A complete staging work-up should be performed to evaluate the extent of disease. In the United States, the standard staging work-up includes the following:\\nCT of the chest and upper abdomen\\nComplete blood count with differential\\nSerum chemistry studies, including creatinine, electrolytes, and calcium\\nAlkaline phosphate\\nAspartate aminotransferase\\nPulmonary function testing\\nMediastinoscopy (if surgical resection is considered)\\nThe information obtained from these tests guides additional testing (eg, imaging studies). Invasive staging procedures (eg, mediastinoscopy, mediastinotomy) may be required to assess mediastinal lymph nodes in patients who may undergo surgical resection. PET may be useful in detecting affected nodes, which may influence decisions about operability.\\nParaneoplastic syndromes are more likely to occur in small cell lung cancer than in non-small cell lung cancer. Patients are at risk for the following:\\nCushing syndrome\\nLambert-Eaton myasthenic syndrome (Onset of proximal lower-extremity weakness is gradual; proximal upper-extremity weakness is usually less noticeable; the syndrome may be worse in the morning and improve during the day; although extraocular muscle involvement is uncommon, ptosis is often found)\\nHypercalcemia (usually occurs with squamous cell carcinoma)\\nSyndrome of inappropriate antidiuretic hormone secretion\\nEnlargement of the extremities and painful, swollen joints (hypertrophic osteoarthropathy)\\n\\n ## Figures\\n\\n \\n*Page 4 of 6*\",\n \"pagination\": {\n \"current_page\": 4,\n \"total_pages\": 6\n },\n \"questionnaire\": [],\n \"title\": \"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\"\n },\n {\n \"authors\": \"Winston W. Tan, MD; Matthew Tan\",\n \"content\": [\n \"The standard treatment for stage I and II disease is surgical resection. In stage IIIA, chemotherapy is indicated, as is surgical resection in selected patients. Standard treatment of stage IIIb is chemoradiation. Stage IV requires cisplatin-based chemotherapy or surgical resection if a solitary metastatic lesion with resectable primary tumor is present.[3,4,5]\",\n \"This patient underwent resection of the cancer. Owing to her residual disease and because her lymph nodes were positive, she was treated with chemoradiation. Surgical resection is the primary modality of treatment for early stage non-small cell lung cancer.[6]\",\n \"Close surveillance of patients with cancer should be the standard after completion of therapy. This patient had a contralateral hilar recurrence 6 years later. When a patient has a recurrence, it must be determined whether it is the same cancer or another primary cancer. This patient had another primary cancer, specifically small cell cancer of the lung. Biopsy must be done of a new recurrence, because it could be an entirely different cancer.\",\n \"Approximately 60%-70% of patients with small cell lung cancer have clinically disseminated or extensive disease at presentation. Extensive-stage small cell lung cancer is incurable. When given combination chemotherapy, patients with extensive-stage disease have a complete response rate of more than 20% and a median survival longer than 7 months; however, only 2% are alive at 5 years.\",\n \"For individuals with limited-stage disease that is treated with combination chemotherapy plus chest radiation, a complete response rate of 80% and survival of 17 months have been reported; 12%-15% of patients are alive at 5 years.[1]\",\n \"Recommendations from the National Comprehensive Cancer Network (NCCN) regarding cancer surveillance in survivors of non-small cell lung cancer include the following:\",\n \"History and physical examination, and chest CT with or without contrast, every 6-12 months for 2 years, then history and physical examination and noncontrast chest CT annually\",\n \"Assessment of smoking status at each visit, with counseling and referral for smoking cessation as needed\",\n \"Other NCCN recommendations for long-term follow-up care include the following:\",\n \"Immunization: Annual influenza vaccination, pneumococcal vaccination with revaccination as appropriate, herpes zoster vaccination\",\n \"Counseling regarding health promotion and wellness (eg, regular physical activity, healthy diet)\",\n \"Routine health monitoring\",\n \"Several important points should be remembered:\",\n \"Persistent cough despite treatment should prompt further diagnostic testing for lung mass.\",\n \"Nonsmokers can develop lung cancer.\",\n \"Neurologic symptoms in patients with lung cancer do not always mean brain metastasis. Although brain metastasis should be ruled out, other causes could be found, such as encephalomalacia.\",\n \"Biopsy of recurrent cancer should be redone, especially if the time to recurrence is more than a few years. A separate cancer can be found in a patient previously cured of their cancer.\",\n \"Several factors may increase the likelihood of a primary cancer resulting in a secondary cancer. A \\\"field effect\\\" is noted in certain types of cancers, particularly in the areas of respiratory tract. In smokers, this is especially true in such areas as the head and neck, throat, laryngeal, esophageal area, and tongue. Because the body's immune system is vulnerable to the development of the first cancer, it may be more susceptible to the development of a second cancer.\"\n ],\n \"date\": \"October 16, 2020\",\n \"figures\": [],\n \"markdown\": \"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\\n\\n **Authors:** Winston W. Tan, MD; Matthew Tan \\n **Date:** October 16, 2020\\n\\n ## Content\\n\\n The standard treatment for stage I and II disease is surgical resection. In stage IIIA, chemotherapy is indicated, as is surgical resection in selected patients. Standard treatment of stage IIIb is chemoradiation. Stage IV requires cisplatin-based chemotherapy or surgical resection if a solitary metastatic lesion with resectable primary tumor is present.[3,4,5]\\nThis patient underwent resection of the cancer. Owing to her residual disease and because her lymph nodes were positive, she was treated with chemoradiation. Surgical resection is the primary modality of treatment for early stage non-small cell lung cancer.[6]\\nClose surveillance of patients with cancer should be the standard after completion of therapy. This patient had a contralateral hilar recurrence 6 years later. When a patient has a recurrence, it must be determined whether it is the same cancer or another primary cancer. This patient had another primary cancer, specifically small cell cancer of the lung. Biopsy must be done of a new recurrence, because it could be an entirely different cancer.\\nApproximately 60%-70% of patients with small cell lung cancer have clinically disseminated or extensive disease at presentation. Extensive-stage small cell lung cancer is incurable. When given combination chemotherapy, patients with extensive-stage disease have a complete response rate of more than 20% and a median survival longer than 7 months; however, only 2% are alive at 5 years.\\nFor individuals with limited-stage disease that is treated with combination chemotherapy plus chest radiation, a complete response rate of 80% and survival of 17 months have been reported; 12%-15% of patients are alive at 5 years.[1]\\nRecommendations from the National Comprehensive Cancer Network (NCCN) regarding cancer surveillance in survivors of non-small cell lung cancer include the following:\\nHistory and physical examination, and chest CT with or without contrast, every 6-12 months for 2 years, then history and physical examination and noncontrast chest CT annually\\nAssessment of smoking status at each visit, with counseling and referral for smoking cessation as needed\\nOther NCCN recommendations for long-term follow-up care include the following:\\nImmunization: Annual influenza vaccination, pneumococcal vaccination with revaccination as appropriate, herpes zoster vaccination\\nCounseling regarding health promotion and wellness (eg, regular physical activity, healthy diet)\\nRoutine health monitoring\\nSeveral important points should be remembered:\\nPersistent cough despite treatment should prompt further diagnostic testing for lung mass.\\nNonsmokers can develop lung cancer.\\nNeurologic symptoms in patients with lung cancer do not always mean brain metastasis. Although brain metastasis should be ruled out, other causes could be found, such as encephalomalacia.\\nBiopsy of recurrent cancer should be redone, especially if the time to recurrence is more than a few years. A separate cancer can be found in a patient previously cured of their cancer.\\nSeveral factors may increase the likelihood of a primary cancer resulting in a secondary cancer. A \\\"field effect\\\" is noted in certain types of cancers, particularly in the areas of respiratory tract. In smokers, this is especially true in such areas as the head and neck, throat, laryngeal, esophageal area, and tongue. Because the body's immune system is vulnerable to the development of the first cancer, it may be more susceptible to the development of a second cancer.\\n\\n ## Figures\\n\\n \\n*Page 5 of 6*\",\n \"pagination\": {\n \"current_page\": 5,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831365,\n \"choiceText\": \"Adenocarcinoma\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831367,\n \"choiceText\": \"Squamous cell carcinoma\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831369,\n \"choiceText\": \"Large-cell carcinoma\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831371,\n \"choiceText\": \"None of the above\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"The most common metabolic abnormality associated with non-small cell lung cancer is hypercalcemia, which usually occurs with squamous cell carcinoma and results from secretion of parathyroid hormone-related peptide by the tumor. This can be distinguished from hyperparathyroidism by confirmation of normal serum parathyroid hormone levels.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261413,\n \"questionText\": \"Which of the following is most commonly associated with hypercalcemia in patients with non-small cell lung cancer?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831373,\n \"choiceText\": \"Smoke exposure\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831375,\n \"choiceText\": \"Family history\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831377,\n \"choiceText\": \"Poor diet\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831379,\n \"choiceText\": \"Chemical exposure\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Smoking is the most well-recognized risk factor for lung cancer. Even secondhand exposure carries a significant risk. In addition, exposure to certain gases (eg, radon), asbestos, and other chemicals may increase the risk for lung cancer. Likewise, a family history of lung cancer increases risk for the disease.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261415,\n \"questionText\": \"Which of the following is <i>not</i> considered a primary risk factor for lung cancer?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\"\n },\n {\n \"authors\": \"Winston W. Tan, MD; Matthew Tan\",\n \"content\": [],\n \"date\": \"October 16, 2020\",\n \"figures\": [],\n \"markdown\": \"# Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\\n\\n **Authors:** Winston W. Tan, MD; Matthew Tan \\n **Date:** October 16, 2020\\n\\n ## Content\\n\\n \\n\\n ## Figures\\n\\n \\n*Page 6 of 6*\",\n \"pagination\": {\n \"current_page\": 6,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831365,\n \"choiceText\": \"Adenocarcinoma\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831367,\n \"choiceText\": \"Squamous cell carcinoma\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831369,\n \"choiceText\": \"Large-cell carcinoma\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831371,\n \"choiceText\": \"None of the above\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"The most common metabolic abnormality associated with non-small cell lung cancer is hypercalcemia, which usually occurs with squamous cell carcinoma and results from secretion of parathyroid hormone-related peptide by the tumor. This can be distinguished from hyperparathyroidism by confirmation of normal serum parathyroid hormone levels.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261413,\n \"questionText\": \"Which of the following is most commonly associated with hypercalcemia in patients with non-small cell lung cancer?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831373,\n \"choiceText\": \"Smoke exposure\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831375,\n \"choiceText\": \"Family history\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831377,\n \"choiceText\": \"Poor diet\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831379,\n \"choiceText\": \"Chemical exposure\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Smoking is the most well-recognized risk factor for lung cancer. Even secondhand exposure carries a significant risk. In addition, exposure to certain gases (eg, radon), asbestos, and other chemicals may increase the risk for lung cancer. Likewise, a family history of lung cancer increases risk for the disease.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261415,\n \"questionText\": \"Which of the following is <i>not</i> considered a primary risk factor for lung cancer?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old\"\n }\n]","isConversational":false},"questions":{"kind":"list like","value":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831357,"choiceText":"Sarcoidosis","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831359,"choiceText":"Lung cancer","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831361,"choiceText":"Tuberculosis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831363,"choiceText":"Pneumonia \r\n","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261411,"questionText":"Based only on these findings, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831365,"choiceText":"Adenocarcinoma","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831367,"choiceText":"Squamous cell carcinoma","correct":true,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831369,"choiceText":"Large-cell carcinoma","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831371,"choiceText":"None of the above\r\n","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"The most common metabolic abnormality associated with non-small cell lung cancer is hypercalcemia, which usually occurs with squamous cell carcinoma and results from secretion of parathyroid hormone-related peptide by the tumor. This can be distinguished from hyperparathyroidism by confirmation of normal serum parathyroid hormone levels.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261413,"questionText":"Which of the following is most commonly associated with hypercalcemia in patients with non-small cell lung cancer?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":831373,"choiceText":"Smoke exposure","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831375,"choiceText":"Family history","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831377,"choiceText":"Poor diet","correct":true,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":831379,"choiceText":"Chemical exposure","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Smoking is the most well-recognized risk factor for lung cancer. Even secondhand exposure carries a significant risk. In addition, exposure to certain gases (eg, radon), asbestos, and other chemicals may increase the risk for lung cancer. Likewise, a family history of lung cancer increases risk for the disease.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":261415,"questionText":"Which of the following is <i>not</i> considered a primary risk factor for lung cancer?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"string":"[\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831357,\n \"choiceText\": \"Sarcoidosis\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831359,\n \"choiceText\": \"Lung cancer\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831361,\n \"choiceText\": \"Tuberculosis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831363,\n \"choiceText\": \"Pneumonia \\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261411,\n \"questionText\": \"Based only on these findings, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831365,\n \"choiceText\": \"Adenocarcinoma\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831367,\n \"choiceText\": \"Squamous cell carcinoma\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831369,\n \"choiceText\": \"Large-cell carcinoma\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831371,\n \"choiceText\": \"None of the above\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"The most common metabolic abnormality associated with non-small cell lung cancer is hypercalcemia, which usually occurs with squamous cell carcinoma and results from secretion of parathyroid hormone-related peptide by the tumor. This can be distinguished from hyperparathyroidism by confirmation of normal serum parathyroid hormone levels.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261413,\n \"questionText\": \"Which of the following is most commonly associated with hypercalcemia in patients with non-small cell lung cancer?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 831373,\n \"choiceText\": \"Smoke exposure\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831375,\n \"choiceText\": \"Family history\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831377,\n \"choiceText\": \"Poor diet\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 831379,\n \"choiceText\": \"Chemical exposure\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Smoking is the most well-recognized risk factor for lung cancer. Even secondhand exposure carries a significant risk. In addition, exposure to certain gases (eg, radon), asbestos, and other chemicals may increase the risk for lung cancer. Likewise, a family history of lung cancer increases risk for the disease.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 261415,\n \"questionText\": \"Which of the following is <i>not</i> considered a primary risk factor for lung cancer?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n]","isConversational":false}}},{"rowIdx":298,"cells":{"article_id":{"kind":"string","value":"938423"},"url":{"kind":"string","value":"/viewarticle/938423"},"article_data":{"kind":"list like","value":[{"authors":"Timothy D. Murphy, MD","content":["Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us .","A 5-year-old girl with a long-standing history of severe asthma and eczema presented to a pediatric pulmonary and sleep medicine clinic. Her asthma was stabilized with an inhaled corticosteroid (fluticasone, 88 µg, inhaled twice daily), albuterol sulfate (180 µg, inhaled as needed), and ipratropium bromide (34 µg, inhaled as needed). Her skin condition improved with a moderately aggressive regimen of hydrating bleach baths, moisturizing lotions, nonsedating antihistamines, and as-needed use of topical hydrocortisone or triamcinolone, pimecrolimus, and mupirocin.","Her asthma remained stable for a year but then progressed to the extent that the dosage of inhaled fluticasone was increased to 220 µg twice daily. Bronchoscopy revealed only mild bronchomalacia of the left mainstem bronchus (Figure 1), diffuse mild inflammation, and increased secretions.","Figure 1.","Montelukast (5 mg daily) and nasal fluticasone (50 µg) were added to her regimen. In addition, diphenhydramine (25 mg) was prescribed to be used as needed for excessive itchiness, eczema flares, and allergic asthma flares.","The patient remained well and was followed up in the clinic approximately every 3 months, owing to the complexity of her condition. After 6 months, significant weight gain and an increasing body mass index (BMI) were noted. She met with a dietitian, who recommended weight loss strategies. From the age of 7-8 years, the patient demonstrated a modest weight loss from the changes in her diet. However, symptoms of fatigue, excessive daytime sleepiness (EDS), and inattention in school developed over a 1- to 2-month period, and her weight started to increase rapidly despite the dietary intervention.","Her daytime sleepiness seemed to be progressive, and she would fall asleep suddenly even when she wanted to be awake. Concerned about the emerging symptoms of inattention, autistic features, fatigue, and sleepiness, the girl's parents are seeking further medical advice."],"date":"October 09, 2020","figures":[{"caption":"Figure 1.","image_url":"https://img.medscapestatic.com/article/938/423/938423-Thumb1.jpg"}],"markdown":"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\n\n **Authors:** Timothy D. Murphy, MD \n **Date:** October 09, 2020\n\n ## Content\n\n Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us .\nA 5-year-old girl with a long-standing history of severe asthma and eczema presented to a pediatric pulmonary and sleep medicine clinic. Her asthma was stabilized with an inhaled corticosteroid (fluticasone, 88 µg, inhaled twice daily), albuterol sulfate (180 µg, inhaled as needed), and ipratropium bromide (34 µg, inhaled as needed). Her skin condition improved with a moderately aggressive regimen of hydrating bleach baths, moisturizing lotions, nonsedating antihistamines, and as-needed use of topical hydrocortisone or triamcinolone, pimecrolimus, and mupirocin.\nHer asthma remained stable for a year but then progressed to the extent that the dosage of inhaled fluticasone was increased to 220 µg twice daily. Bronchoscopy revealed only mild bronchomalacia of the left mainstem bronchus (Figure 1), diffuse mild inflammation, and increased secretions.\nFigure 1.\nMontelukast (5 mg daily) and nasal fluticasone (50 µg) were added to her regimen. In addition, diphenhydramine (25 mg) was prescribed to be used as needed for excessive itchiness, eczema flares, and allergic asthma flares.\nThe patient remained well and was followed up in the clinic approximately every 3 months, owing to the complexity of her condition. After 6 months, significant weight gain and an increasing body mass index (BMI) were noted. She met with a dietitian, who recommended weight loss strategies. From the age of 7-8 years, the patient demonstrated a modest weight loss from the changes in her diet. However, symptoms of fatigue, excessive daytime sleepiness (EDS), and inattention in school developed over a 1- to 2-month period, and her weight started to increase rapidly despite the dietary intervention.\nHer daytime sleepiness seemed to be progressive, and she would fall asleep suddenly even when she wanted to be awake. Concerned about the emerging symptoms of inattention, autistic features, fatigue, and sleepiness, the girl's parents are seeking further medical advice.\n\n ## Figures\n\n **Figure 1.** \n \n\n\n*Page 1 of 6*","pagination":{"current_page":1,"total_pages":6},"questionnaire":[],"title":"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma"},{"authors":"Timothy D. Murphy, MD","content":["The patient has fallen asleep at school nearly every day for the past 1-2 months and falls into a deep sleep unless she is kept active. At home, she is taking more naps during the day, falling asleep in the car, and struggling with schoolwork. Her grades have dropped significantly over the past few months. Her parents report that she does not awaken during the night. No snoring, choking, snorting, gasping, or apnea is noted. She sleeps an average of 9-10 hours per night but is restless and tosses and turns frequently in her sleep.","Her family history is notable for obesity, obstructive sleep apnea (OSA) that requires continuous positive airway pressure (CPAP) in her father, and narcolepsy in an uncle and a grandfather.","On physical examination, she has mild to moderate obesity (BMI of 23.89 kg/m2 [the 98th percentile for age]) and enlarged tonsils (2-3+). She has difficulty with focusing and staying awake in the clinic.","She is referred to a pediatric otolaryngologist for consideration of nocturnal polysomnography (NPSG) or an adenotonsillectomy. The otolaryngologist notes that she has not tolerated nasal fluticasone well, that she is a chronic mouth breather, and that her tonsils are enlarged (3+). An NPSG is ordered to help clarify matters.","The NPSG demonstrates the following:","A respiratory disturbance index and an apnea-hypopnea index (AHI) of 6.2 per hour","Sleep latency of 0.5 minutes and rapid eye movement (REM) latency of 0.5 minutes","A sleep efficiency of 87.5%","18.2% of total sleep time in stage N1, 36.4% in N2, 29.9% in N3, and 15.5% in REM sleep","An arousal index of 18.6","A periodic leg movement index of 6.3","Multiple periods of wakefulness scattered throughout the night and six REM periods"],"date":"October 09, 2020","figures":[],"markdown":"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\n\n **Authors:** Timothy D. Murphy, MD \n **Date:** October 09, 2020\n\n ## Content\n\n The patient has fallen asleep at school nearly every day for the past 1-2 months and falls into a deep sleep unless she is kept active. At home, she is taking more naps during the day, falling asleep in the car, and struggling with schoolwork. Her grades have dropped significantly over the past few months. Her parents report that she does not awaken during the night. No snoring, choking, snorting, gasping, or apnea is noted. She sleeps an average of 9-10 hours per night but is restless and tosses and turns frequently in her sleep.\nHer family history is notable for obesity, obstructive sleep apnea (OSA) that requires continuous positive airway pressure (CPAP) in her father, and narcolepsy in an uncle and a grandfather.\nOn physical examination, she has mild to moderate obesity (BMI of 23.89 kg/m2 [the 98th percentile for age]) and enlarged tonsils (2-3+). She has difficulty with focusing and staying awake in the clinic.\nShe is referred to a pediatric otolaryngologist for consideration of nocturnal polysomnography (NPSG) or an adenotonsillectomy. The otolaryngologist notes that she has not tolerated nasal fluticasone well, that she is a chronic mouth breather, and that her tonsils are enlarged (3+). An NPSG is ordered to help clarify matters.\nThe NPSG demonstrates the following:\nA respiratory disturbance index and an apnea-hypopnea index (AHI) of 6.2 per hour\nSleep latency of 0.5 minutes and rapid eye movement (REM) latency of 0.5 minutes\nA sleep efficiency of 87.5%\n18.2% of total sleep time in stage N1, 36.4% in N2, 29.9% in N3, and 15.5% in REM sleep\nAn arousal index of 18.6\nA periodic leg movement index of 6.3\nMultiple periods of wakefulness scattered throughout the night and six REM periods\n\n ## Figures\n\n \n*Page 2 of 6*","pagination":{"current_page":2,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529064,"choiceText":"Behavioral insomnia of childhood\r\n","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529065,"choiceText":"Pediatric chronic obstructive pulmonary disease","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529066,"choiceText":"Delayed sleep phase disorder","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529067,"choiceText":"Narcolepsy","correct":true,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490073,"questionText":"On the basis of these findings only, what is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma"},{"authors":"Timothy D. Murphy, MD","content":["This case is very challenging because the patient had the findings of and met the criteria for OSA, periodic limb movement disorder (PLMD)/restless legs syndrome (RLS), and hypersomnolence. She also had several historical findings that were highly suggestive of narcolepsy with cataplexy. These included a strong family history of narcolepsy, a history of the sudden onset of sleep and greatly increased sleep pressure, and rapid weight gain. A critical finding was a nocturnal sleep-onset REM sleep period (SOREMP). A nocturnal SOREMP (defined as REM sleep within 15 minutes of falling asleep) has a very high specificity for narcolepsy with cataplexy in adults and children.[1,2] However, the importance of the nocturnal SOREMP was not initially noted in her evaluation and management.","OSA and PLMD were initially diagnosed, and the otolaryngologist performed an adenotonsillectomy. The patient returned to the pediatric pulmonary and sleep medicine clinic after the procedure. At 3 weeks after the surgery, her somnolence improved very little. She had been gaining weight more rapidly and symptoms of apparent instability in her asthma were noted.","Further history-taking revealed a complex set of interactions around eating (some involved her father catering to her desire for higher-carbohydrate foods), increased sedentary behavior, and a history suggestive of vocal cord dysfunction. She was having \"asthma attacks\" characterized by rapid onset with inspiratory stridor and rapid resolution at the onset of activity. Her family was willing to make changes in their diet and to encourage activity, and they sought help for the vocal cord dysfunction from a speech and language pathologist.","Despite these measures, her weight gain rapidly progressed and the daytime fatigue and sleepiness continued. The pediatrician referred her to the neurologist who had interpreted the first NPSG. His history presented a differential diagnosis of narcolepsy, primary hypersomnolence, persistent OSA, and PLMD. He recommended a second NPSG with a multiple sleep latency test (MSLT), to be done immediately following the NPSG to assess her sleepiness more formally. His history documented that she felt as if she was \"going to fall\" when she laughed. He also noted that her father had OSA (treated with CPAP) and that she had an uncle and a grandfather with narcolepsy.","The second NPSG revealed the following:","A respiratory disturbance index of 1.4 (improved)","Sleep latency of 2.5 minutes and REM latency of 68.5 minutes","A sleep efficiency of 68.3%","31.6% of total sleep time in stage N1, 43.8% in N2, 20% in N3, and 4.6% in REM sleep","An arousal index of 23.5 (increased)","A periodic leg movement index of 5.9 (slightly lower)","\"3 REM periods, 2 of them were very brief,\" and a period of wakefulness after sleep onset of 180.5 minutes (increased)","The MSLT showed a mean sleep latency calculated at 9.5 minutes and no sleep onset–associated REM sleep (REM sleep within 20 minutes of sleep onset).","The neurologist provisionally diagnosed narcolepsy (vs hypersomnolence). He prescribed methylphenidate and then gradually increased the dose. Despite slightly improved daytime alertness, the patient started to develop more classic findings of cataplexy. The patient's mother brought her back to the pediatric pulmonary and sleep medicine clinic. Methylphenidate was discontinued and therapy with modafinil was initiated.","When the patient was 9 years old, sodium oxybate was added to her regimen and her condition finally stabilized. Her therapy was complicated by the treatment of her inattention with dextroamphetamine and levoamphetamine (Adderall) and the effects of all of her therapy on her weight. Her rapid weight gain was followed by an equally rapid weight loss, and these changes finally settled into her currently stable pattern of tracking around the 75th percentile after starting sodium oxybate (Figure 2).","Figure 2."],"date":"October 09, 2020","figures":[{"caption":"Figure 2.","image_url":"https://img.medscapestatic.com/article/938/423/938423-Thumb2.jpg"}],"markdown":"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\n\n **Authors:** Timothy D. Murphy, MD \n **Date:** October 09, 2020\n\n ## Content\n\n This case is very challenging because the patient had the findings of and met the criteria for OSA, periodic limb movement disorder (PLMD)/restless legs syndrome (RLS), and hypersomnolence. She also had several historical findings that were highly suggestive of narcolepsy with cataplexy. These included a strong family history of narcolepsy, a history of the sudden onset of sleep and greatly increased sleep pressure, and rapid weight gain. A critical finding was a nocturnal sleep-onset REM sleep period (SOREMP). A nocturnal SOREMP (defined as REM sleep within 15 minutes of falling asleep) has a very high specificity for narcolepsy with cataplexy in adults and children.[1,2] However, the importance of the nocturnal SOREMP was not initially noted in her evaluation and management.\nOSA and PLMD were initially diagnosed, and the otolaryngologist performed an adenotonsillectomy. The patient returned to the pediatric pulmonary and sleep medicine clinic after the procedure. At 3 weeks after the surgery, her somnolence improved very little. She had been gaining weight more rapidly and symptoms of apparent instability in her asthma were noted.\nFurther history-taking revealed a complex set of interactions around eating (some involved her father catering to her desire for higher-carbohydrate foods), increased sedentary behavior, and a history suggestive of vocal cord dysfunction. She was having \"asthma attacks\" characterized by rapid onset with inspiratory stridor and rapid resolution at the onset of activity. Her family was willing to make changes in their diet and to encourage activity, and they sought help for the vocal cord dysfunction from a speech and language pathologist.\nDespite these measures, her weight gain rapidly progressed and the daytime fatigue and sleepiness continued. The pediatrician referred her to the neurologist who had interpreted the first NPSG. His history presented a differential diagnosis of narcolepsy, primary hypersomnolence, persistent OSA, and PLMD. He recommended a second NPSG with a multiple sleep latency test (MSLT), to be done immediately following the NPSG to assess her sleepiness more formally. His history documented that she felt as if she was \"going to fall\" when she laughed. He also noted that her father had OSA (treated with CPAP) and that she had an uncle and a grandfather with narcolepsy.\nThe second NPSG revealed the following:\nA respiratory disturbance index of 1.4 (improved)\nSleep latency of 2.5 minutes and REM latency of 68.5 minutes\nA sleep efficiency of 68.3%\n31.6% of total sleep time in stage N1, 43.8% in N2, 20% in N3, and 4.6% in REM sleep\nAn arousal index of 23.5 (increased)\nA periodic leg movement index of 5.9 (slightly lower)\n\"3 REM periods, 2 of them were very brief,\" and a period of wakefulness after sleep onset of 180.5 minutes (increased)\nThe MSLT showed a mean sleep latency calculated at 9.5 minutes and no sleep onset–associated REM sleep (REM sleep within 20 minutes of sleep onset).\nThe neurologist provisionally diagnosed narcolepsy (vs hypersomnolence). He prescribed methylphenidate and then gradually increased the dose. Despite slightly improved daytime alertness, the patient started to develop more classic findings of cataplexy. The patient's mother brought her back to the pediatric pulmonary and sleep medicine clinic. Methylphenidate was discontinued and therapy with modafinil was initiated.\nWhen the patient was 9 years old, sodium oxybate was added to her regimen and her condition finally stabilized. Her therapy was complicated by the treatment of her inattention with dextroamphetamine and levoamphetamine (Adderall) and the effects of all of her therapy on her weight. Her rapid weight gain was followed by an equally rapid weight loss, and these changes finally settled into her currently stable pattern of tracking around the 75th percentile after starting sodium oxybate (Figure 2).\nFigure 2.\n\n ## Figures\n\n **Figure 2.** \n \n\n\n*Page 3 of 6*","pagination":{"current_page":3,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529064,"choiceText":"Behavioral insomnia of childhood\r\n","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529065,"choiceText":"Pediatric chronic obstructive pulmonary disease","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529066,"choiceText":"Delayed sleep phase disorder","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529067,"choiceText":"Narcolepsy","correct":true,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490073,"questionText":"On the basis of these findings only, what is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma"},{"authors":"Timothy D. Murphy, MD","content":["This case illustrates some of the challenges facing clinicians who care for a \"sleepy child.\" In the evolution of this child's care, multiple diagnoses were made and treated. The failure of her symptoms to respond to treatment resulted in further evaluation (and reevaluation of the data), which finally led to the diagnosis (narcolepsy with cataplexy) and her ultimate improvement and stabilization.","Hypersomnolence may be primary or it may be secondary to a poor night's sleep. The most common conditions seen in a pediatric sleep clinic that might lead to daytime sleepiness include sleep apnea, behavioral insomnia of childhood, restless sleeping (or, when more extreme, pediatric RLS), and delayed sleep phase disorder (DSPD). The latter is much more common in teenagers, with a prevalence of up to 7% in this age group.[3] However, youths with daytime hypersomnolence due to DSPD do not typically fall asleep easily at bedtime, as this patient did. Moreover, DSPD is unusual in an 8-year-old.","An insufficient quantity of sleep can usually be diagnosed on the basis of the history alone, but actigraphy is occasionally used when the history does not exclude difficulty in falling asleep or a circadian rhythm sleep-wake disorder.[4] Actigraphy was not included in this patient's workup.","Pediatric RLS is primarily diagnosed on the basis of history, but the use of strict criteria (which include that the child \"relates a description in his or her own words\" of leg discomfort) may lead to missing the diagnosis in children who can benefit from treatment but are unable to verbalize their feelings. Suboptimal levels of serum ferritin are associated with restless sleep in children, as is improvement with iron therapy. The use of dopaminergic medications typically requires a higher standard for the diagnosis of RLS and a failure to respond to iron therapy.[5,6] Published data regarding autism and attention-deficit/hyperactivity disorder (ADHD) increasingly suggest complex links between iron metabolism and brain function, including during sleep.[7,8] This patient's movements in bed and her behavioral and learning struggles led to the investigation of her iron stores and ferritin levels and a trial of treatment for RLS.","Hypersomnolence is associated with OSA more commonly in adults than in children. \"Hyperactivity\" or symptoms of ADHD are more frequently observed in children with OSA, although some sleepiness is still noted.[9] Most sleep centers consider an obstructive AHI of fewer than 1 event per hour (some use a threshold of 1.5) to be normal.[10] More pragmatically, the absolute score is useful in choosing a diagnostic billing code, but clinical decision-making also factors in the age of the patient and the severity of observed symptoms, considered formally or as a gestalt.[11]","This patient had a positive AHI, which is diagnostic of OSA, and underwent adenotonsillectomy without significant improvement. She was also treated with iron and vitamin C, without significant changes in her daytime sleepiness or her apparent sleep quality. Furthermore, her clinical care was complicated by the MSLT result, which documented hypersomnolence but not narcolepsy.","The diagnosis of narcolepsy was based primarily on clinical factors. Despite the positive AHI, snoring, leg movements, and low ferritin level, her condition did not improve after the adenotonsillectomy and iron therapy. As her case progressed, she developed more classic symptoms of cataplexy, such as feeling as if she would fall with laughter and falling asleep rapidly in conjunction with strong emotions. These findings, along with the rapid weight gain, pointed toward the diagnosis.","Some confusion along the path toward a diagnosis is common in narcolepsy. Comorbidities, including PLMD, RLS, and OSA, may be found in association with narcolepsy and can delay the diagnosis,[12] as certainly happened in this patient.","Narcolepsy affects about 1 in 2000 people. Two types are recognized: type 1 narcolepsy (previously referred to as narcolepsy with cataplexy) and type 2 narcolepsy (narcolepsy without cataplexy). Type 1 narcolepsy is considered an adult diagnosis by many pediatricians, but it frequently develops during adolescence, and onset after age 40 years is uncommon. Children may first present with a resumption of prolonged naps rather than prolonged nighttime sleep; nocturnal sleep is often somewhat disturbed initially. Cataplexy, multiple short naps during the day, hypnagogic hallucinations, and sleep-onset REM periods may be absent in young children, and repeated NPSGs and MSLTs over months to years may be required to make the diagnosis.","Although a retrospective analysis of sleep histories often reveals hypersomnolence for years prior to the diagnosis, it can be easily missed in the first decade of life.[13] Type 1 narcolepsy is caused by the loss of orexin neuropeptides, which are mediators of central nervous system (CNS) control of energy metabolism and maintenance of sleep-wake states. Rapid weight gain and precocious puberty can occur in children with type 1 narcolepsy. This patient's rapid weight gain started to make more sense once the diagnosis was made.[14]","In type 1 narcolepsy, the lack of consistent REM sleep at night leads to the intrusion of REM sleep features into the waking state. The diagnostic features include the tetrad of daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Specific questioning is usually required to elicit the history; only cataplexy is specific for narcolepsy. Patients often present initially with hypersomnolence alone, and other diagnostic findings may emerge over time.","The etiology of narcolepsy is unclear. The lack of orexin may be related to autoimmune disease or infectious diseases. Most patients with type 1 narcolepsy have HLA DQB1 (0602 allele), the gene complex that encodes for proteins on the surface of T cells. Additionally, some infections (most notably H1N1 influenza, as well as some vaccines for it) are associated with clusters of type 1 narcolepsy and reduced orexin levels.[15,16,17] However, measurement of cerebrospinal fluid (CSF) levels of orexin is not required to make the diagnosis of narcolepsy.","The diagnosis of type 1 narcolepsy can be clinically made in a child with a clear history of cataplexy, EDS, and an otherwise normal neurologic examination. In the absence of cataplexy, an NPSG followed by an MSLT can be used to make the diagnosis of narcolepsy. \"Secondary narcolepsy\" in the setting of CNS diseases such as hypothalamic tumors or arteriovenous malformations, following cerebrovascular accidents, or in association with multiple sclerosis or Niemann-Pick disease type C has been reported, but alternative causes of narcolepsy are vanishingly rare in childhood. The primary challenge is to rule out other sleep disorders causing the EDS; as in this patient, that may be difficult."],"date":"October 09, 2020","figures":[],"markdown":"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\n\n **Authors:** Timothy D. Murphy, MD \n **Date:** October 09, 2020\n\n ## Content\n\n This case illustrates some of the challenges facing clinicians who care for a \"sleepy child.\" In the evolution of this child's care, multiple diagnoses were made and treated. The failure of her symptoms to respond to treatment resulted in further evaluation (and reevaluation of the data), which finally led to the diagnosis (narcolepsy with cataplexy) and her ultimate improvement and stabilization.\nHypersomnolence may be primary or it may be secondary to a poor night's sleep. The most common conditions seen in a pediatric sleep clinic that might lead to daytime sleepiness include sleep apnea, behavioral insomnia of childhood, restless sleeping (or, when more extreme, pediatric RLS), and delayed sleep phase disorder (DSPD). The latter is much more common in teenagers, with a prevalence of up to 7% in this age group.[3] However, youths with daytime hypersomnolence due to DSPD do not typically fall asleep easily at bedtime, as this patient did. Moreover, DSPD is unusual in an 8-year-old.\nAn insufficient quantity of sleep can usually be diagnosed on the basis of the history alone, but actigraphy is occasionally used when the history does not exclude difficulty in falling asleep or a circadian rhythm sleep-wake disorder.[4] Actigraphy was not included in this patient's workup.\nPediatric RLS is primarily diagnosed on the basis of history, but the use of strict criteria (which include that the child \"relates a description in his or her own words\" of leg discomfort) may lead to missing the diagnosis in children who can benefit from treatment but are unable to verbalize their feelings. Suboptimal levels of serum ferritin are associated with restless sleep in children, as is improvement with iron therapy. The use of dopaminergic medications typically requires a higher standard for the diagnosis of RLS and a failure to respond to iron therapy.[5,6] Published data regarding autism and attention-deficit/hyperactivity disorder (ADHD) increasingly suggest complex links between iron metabolism and brain function, including during sleep.[7,8] This patient's movements in bed and her behavioral and learning struggles led to the investigation of her iron stores and ferritin levels and a trial of treatment for RLS.\nHypersomnolence is associated with OSA more commonly in adults than in children. \"Hyperactivity\" or symptoms of ADHD are more frequently observed in children with OSA, although some sleepiness is still noted.[9] Most sleep centers consider an obstructive AHI of fewer than 1 event per hour (some use a threshold of 1.5) to be normal.[10] More pragmatically, the absolute score is useful in choosing a diagnostic billing code, but clinical decision-making also factors in the age of the patient and the severity of observed symptoms, considered formally or as a gestalt.[11]\nThis patient had a positive AHI, which is diagnostic of OSA, and underwent adenotonsillectomy without significant improvement. She was also treated with iron and vitamin C, without significant changes in her daytime sleepiness or her apparent sleep quality. Furthermore, her clinical care was complicated by the MSLT result, which documented hypersomnolence but not narcolepsy.\nThe diagnosis of narcolepsy was based primarily on clinical factors. Despite the positive AHI, snoring, leg movements, and low ferritin level, her condition did not improve after the adenotonsillectomy and iron therapy. As her case progressed, she developed more classic symptoms of cataplexy, such as feeling as if she would fall with laughter and falling asleep rapidly in conjunction with strong emotions. These findings, along with the rapid weight gain, pointed toward the diagnosis.\nSome confusion along the path toward a diagnosis is common in narcolepsy. Comorbidities, including PLMD, RLS, and OSA, may be found in association with narcolepsy and can delay the diagnosis,[12] as certainly happened in this patient.\nNarcolepsy affects about 1 in 2000 people. Two types are recognized: type 1 narcolepsy (previously referred to as narcolepsy with cataplexy) and type 2 narcolepsy (narcolepsy without cataplexy). Type 1 narcolepsy is considered an adult diagnosis by many pediatricians, but it frequently develops during adolescence, and onset after age 40 years is uncommon. Children may first present with a resumption of prolonged naps rather than prolonged nighttime sleep; nocturnal sleep is often somewhat disturbed initially. Cataplexy, multiple short naps during the day, hypnagogic hallucinations, and sleep-onset REM periods may be absent in young children, and repeated NPSGs and MSLTs over months to years may be required to make the diagnosis.\nAlthough a retrospective analysis of sleep histories often reveals hypersomnolence for years prior to the diagnosis, it can be easily missed in the first decade of life.[13] Type 1 narcolepsy is caused by the loss of orexin neuropeptides, which are mediators of central nervous system (CNS) control of energy metabolism and maintenance of sleep-wake states. Rapid weight gain and precocious puberty can occur in children with type 1 narcolepsy. This patient's rapid weight gain started to make more sense once the diagnosis was made.[14]\nIn type 1 narcolepsy, the lack of consistent REM sleep at night leads to the intrusion of REM sleep features into the waking state. The diagnostic features include the tetrad of daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Specific questioning is usually required to elicit the history; only cataplexy is specific for narcolepsy. Patients often present initially with hypersomnolence alone, and other diagnostic findings may emerge over time.\nThe etiology of narcolepsy is unclear. The lack of orexin may be related to autoimmune disease or infectious diseases. Most patients with type 1 narcolepsy have HLA DQB1 (0602 allele), the gene complex that encodes for proteins on the surface of T cells. Additionally, some infections (most notably H1N1 influenza, as well as some vaccines for it) are associated with clusters of type 1 narcolepsy and reduced orexin levels.[15,16,17] However, measurement of cerebrospinal fluid (CSF) levels of orexin is not required to make the diagnosis of narcolepsy.\nThe diagnosis of type 1 narcolepsy can be clinically made in a child with a clear history of cataplexy, EDS, and an otherwise normal neurologic examination. In the absence of cataplexy, an NPSG followed by an MSLT can be used to make the diagnosis of narcolepsy. \"Secondary narcolepsy\" in the setting of CNS diseases such as hypothalamic tumors or arteriovenous malformations, following cerebrovascular accidents, or in association with multiple sclerosis or Niemann-Pick disease type C has been reported, but alternative causes of narcolepsy are vanishingly rare in childhood. The primary challenge is to rule out other sleep disorders causing the EDS; as in this patient, that may be difficult.\n\n ## Figures\n\n \n*Page 4 of 6*","pagination":{"current_page":4,"total_pages":6},"questionnaire":[],"title":"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma"},{"authors":"Timothy D. Murphy, MD","content":["The treatment of narcolepsy focuses first on attempts to reduce the EDS pharmacologically; timed naps or increased time in bed is not usually sufficient to reduce the EDS. Although many medications have been used to treat EDS, clinicians typically start with caffeine (usually inadequate) and then move to stronger stimulants, such as methylphenidate or amphetamine and dextroamphetamine in combination.","Failure of these agents might then lead to the use of modafinil (prescription without the failure of other therapies is often difficult). Monitoring of response and fairly frequent visits are required at this point. A selective serotonin reuptake inhibitor, such as fluoxetine, is often added to the regimen of patients with classic cataplexy. As was the case for this patient, the use of medications that might affect mood, attention, learning, and sleep requires close attention and collaboration between specialists in sleep medicine, neurology, and behavioral and general pediatrics.","In some patients, including this patient, sodium oxybate (gamma-hydroxybutyrate [GHB]) is required to treat the cataplexy and to lead to better daytime functioning.[18] The exact mechanism of action is unknown, but the evening dosing of GHB is associated with improved REM sleep at night, perhaps relieving the intrusion of REM during daytime wake periods associated with type 1 narcolepsy. Unfortunately, GHB is associated with abuse — it is often called the \"date rape drug\" — and is now tightly regulated. Prescription in the United States is limited to one US pharmacy, and a sleep physician is typically required to obtain and use this medication.","The finding of EDS requires exploration of nocturnal problems with sleep, including RLS, OSA, and behavioral insomnia that affects daytime functioning. Narcolepsy can be diagnosed as the cause of EDS on the basis of careful history-taking as well as the results of an NPSG and an MSLT."],"date":"October 09, 2020","figures":[],"markdown":"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\n\n **Authors:** Timothy D. Murphy, MD \n **Date:** October 09, 2020\n\n ## Content\n\n The treatment of narcolepsy focuses first on attempts to reduce the EDS pharmacologically; timed naps or increased time in bed is not usually sufficient to reduce the EDS. Although many medications have been used to treat EDS, clinicians typically start with caffeine (usually inadequate) and then move to stronger stimulants, such as methylphenidate or amphetamine and dextroamphetamine in combination.\nFailure of these agents might then lead to the use of modafinil (prescription without the failure of other therapies is often difficult). Monitoring of response and fairly frequent visits are required at this point. A selective serotonin reuptake inhibitor, such as fluoxetine, is often added to the regimen of patients with classic cataplexy. As was the case for this patient, the use of medications that might affect mood, attention, learning, and sleep requires close attention and collaboration between specialists in sleep medicine, neurology, and behavioral and general pediatrics.\nIn some patients, including this patient, sodium oxybate (gamma-hydroxybutyrate [GHB]) is required to treat the cataplexy and to lead to better daytime functioning.[18] The exact mechanism of action is unknown, but the evening dosing of GHB is associated with improved REM sleep at night, perhaps relieving the intrusion of REM during daytime wake periods associated with type 1 narcolepsy. Unfortunately, GHB is associated with abuse — it is often called the \"date rape drug\" — and is now tightly regulated. Prescription in the United States is limited to one US pharmacy, and a sleep physician is typically required to obtain and use this medication.\nThe finding of EDS requires exploration of nocturnal problems with sleep, including RLS, OSA, and behavioral insomnia that affects daytime functioning. Narcolepsy can be diagnosed as the cause of EDS on the basis of careful history-taking as well as the results of an NPSG and an MSLT.\n\n ## Figures\n\n \n*Page 5 of 6*","pagination":{"current_page":5,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529068,"choiceText":"Narcolepsy without cataplexy (type 2 narcolepsy) is associated with increased orexin neuropeptide levels","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529069,"choiceText":"Childhood narcolepsy is characterized by multiple brief naps during the day","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529070,"choiceText":"Narcolepsy is associated with the loss of orexin neuropeptides","correct":true,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529071,"choiceText":"Measurement of orexin levels in the CSF is required for the diagnosis of narcolepsy","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Levels of orexin neuropeptides in the CNS are reduced, not increased, in all forms of narcolepsy. Children more frequently present with prolonged daytime sleep, and multiple naps are typically seen in older patients. The diagnosis can be made by a careful history-taking that documents cataplexy, which is explained only by type 1 narcolepsy. Measurement of CSF levels of orexin is usually related to research only and typically is not used clinically in diagnosing narcolepsy.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490074,"questionText":"Which of the following is most accurate regarding narcolepsy in children?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529072,"choiceText":"Timed or planned naps to reduce sleep pressure, and amphetamine and dextroamphetamine for stimulant therapy during the day\r\n","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529073,"choiceText":"Modafinil as a daytime stimulant, fluoxetine for cataplexy, and sodium oxybate to improve REM efficiency","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529074,"choiceText":"Caffeine as a morning stimulant and sodium oxybate (gamma-hydroxybutyrate [GHB]) used at night to consolidate non-REM sleep","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529075,"choiceText":"Methylphenidate to reduce cataplexy, fluoxetine to reduce depressive symptoms, and sodium oxybate to prolong REM latency","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Caffeine is usually an inadequate stimulant for patients with narcolepsy. The daytime use of methylphenidate or amphetamine and dextroamphetamine in combination does not adequately reduce cataplexy and does not address the problem with REM sleep at night. Modafinil is a more reliable daytime stimulant, and fluoxetine helps reduce cataplexy. The use of sodium oxybate in the evening in divided doses is intended to consolidate REM sleep and may reduce REM latency; non-REM sleep is not related to the daytime difficulties associated with narcolepsy.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490075,"questionText":"Which of the following is typically required in the treatment of type 1 narcolepsy?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma"},{"authors":"Timothy D. Murphy, MD","content":[],"date":"October 09, 2020","figures":[],"markdown":"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\n\n **Authors:** Timothy D. Murphy, MD \n **Date:** October 09, 2020\n\n ## Content\n\n \n\n ## Figures\n\n \n*Page 6 of 6*","pagination":{"current_page":6,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529068,"choiceText":"Narcolepsy without cataplexy (type 2 narcolepsy) is associated with increased orexin neuropeptide levels","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529069,"choiceText":"Childhood narcolepsy is characterized by multiple brief naps during the day","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529070,"choiceText":"Narcolepsy is associated with the loss of orexin neuropeptides","correct":true,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529071,"choiceText":"Measurement of orexin levels in the CSF is required for the diagnosis of narcolepsy","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Levels of orexin neuropeptides in the CNS are reduced, not increased, in all forms of narcolepsy. Children more frequently present with prolonged daytime sleep, and multiple naps are typically seen in older patients. The diagnosis can be made by a careful history-taking that documents cataplexy, which is explained only by type 1 narcolepsy. Measurement of CSF levels of orexin is usually related to research only and typically is not used clinically in diagnosing narcolepsy.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490074,"questionText":"Which of the following is most accurate regarding narcolepsy in children?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529072,"choiceText":"Timed or planned naps to reduce sleep pressure, and amphetamine and dextroamphetamine for stimulant therapy during the day\r\n","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529073,"choiceText":"Modafinil as a daytime stimulant, fluoxetine for cataplexy, and sodium oxybate to improve REM efficiency","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529074,"choiceText":"Caffeine as a morning stimulant and sodium oxybate (gamma-hydroxybutyrate [GHB]) used at night to consolidate non-REM sleep","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529075,"choiceText":"Methylphenidate to reduce cataplexy, fluoxetine to reduce depressive symptoms, and sodium oxybate to prolong REM latency","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Caffeine is usually an inadequate stimulant for patients with narcolepsy. The daytime use of methylphenidate or amphetamine and dextroamphetamine in combination does not adequately reduce cataplexy and does not address the problem with REM sleep at night. Modafinil is a more reliable daytime stimulant, and fluoxetine helps reduce cataplexy. The use of sodium oxybate in the evening in divided doses is intended to consolidate REM sleep and may reduce REM latency; non-REM sleep is not related to the daytime difficulties associated with narcolepsy.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490075,"questionText":"Which of the following is typically required in the treatment of type 1 narcolepsy?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma"}],"string":"[\n {\n \"authors\": \"Timothy D. Murphy, MD\",\n \"content\": [\n \"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us .\",\n \"A 5-year-old girl with a long-standing history of severe asthma and eczema presented to a pediatric pulmonary and sleep medicine clinic. Her asthma was stabilized with an inhaled corticosteroid (fluticasone, 88 µg, inhaled twice daily), albuterol sulfate (180 µg, inhaled as needed), and ipratropium bromide (34 µg, inhaled as needed). Her skin condition improved with a moderately aggressive regimen of hydrating bleach baths, moisturizing lotions, nonsedating antihistamines, and as-needed use of topical hydrocortisone or triamcinolone, pimecrolimus, and mupirocin.\",\n \"Her asthma remained stable for a year but then progressed to the extent that the dosage of inhaled fluticasone was increased to 220 µg twice daily. Bronchoscopy revealed only mild bronchomalacia of the left mainstem bronchus (Figure 1), diffuse mild inflammation, and increased secretions.\",\n \"Figure 1.\",\n \"Montelukast (5 mg daily) and nasal fluticasone (50 µg) were added to her regimen. In addition, diphenhydramine (25 mg) was prescribed to be used as needed for excessive itchiness, eczema flares, and allergic asthma flares.\",\n \"The patient remained well and was followed up in the clinic approximately every 3 months, owing to the complexity of her condition. After 6 months, significant weight gain and an increasing body mass index (BMI) were noted. She met with a dietitian, who recommended weight loss strategies. From the age of 7-8 years, the patient demonstrated a modest weight loss from the changes in her diet. However, symptoms of fatigue, excessive daytime sleepiness (EDS), and inattention in school developed over a 1- to 2-month period, and her weight started to increase rapidly despite the dietary intervention.\",\n \"Her daytime sleepiness seemed to be progressive, and she would fall asleep suddenly even when she wanted to be awake. Concerned about the emerging symptoms of inattention, autistic features, fatigue, and sleepiness, the girl's parents are seeking further medical advice.\"\n ],\n \"date\": \"October 09, 2020\",\n \"figures\": [\n {\n \"caption\": \"Figure 1.\",\n \"image_url\": \"https://img.medscapestatic.com/article/938/423/938423-Thumb1.jpg\"\n }\n ],\n \"markdown\": \"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\\n\\n **Authors:** Timothy D. Murphy, MD \\n **Date:** October 09, 2020\\n\\n ## Content\\n\\n Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us .\\nA 5-year-old girl with a long-standing history of severe asthma and eczema presented to a pediatric pulmonary and sleep medicine clinic. Her asthma was stabilized with an inhaled corticosteroid (fluticasone, 88 µg, inhaled twice daily), albuterol sulfate (180 µg, inhaled as needed), and ipratropium bromide (34 µg, inhaled as needed). Her skin condition improved with a moderately aggressive regimen of hydrating bleach baths, moisturizing lotions, nonsedating antihistamines, and as-needed use of topical hydrocortisone or triamcinolone, pimecrolimus, and mupirocin.\\nHer asthma remained stable for a year but then progressed to the extent that the dosage of inhaled fluticasone was increased to 220 µg twice daily. Bronchoscopy revealed only mild bronchomalacia of the left mainstem bronchus (Figure 1), diffuse mild inflammation, and increased secretions.\\nFigure 1.\\nMontelukast (5 mg daily) and nasal fluticasone (50 µg) were added to her regimen. In addition, diphenhydramine (25 mg) was prescribed to be used as needed for excessive itchiness, eczema flares, and allergic asthma flares.\\nThe patient remained well and was followed up in the clinic approximately every 3 months, owing to the complexity of her condition. After 6 months, significant weight gain and an increasing body mass index (BMI) were noted. She met with a dietitian, who recommended weight loss strategies. From the age of 7-8 years, the patient demonstrated a modest weight loss from the changes in her diet. However, symptoms of fatigue, excessive daytime sleepiness (EDS), and inattention in school developed over a 1- to 2-month period, and her weight started to increase rapidly despite the dietary intervention.\\nHer daytime sleepiness seemed to be progressive, and she would fall asleep suddenly even when she wanted to be awake. Concerned about the emerging symptoms of inattention, autistic features, fatigue, and sleepiness, the girl's parents are seeking further medical advice.\\n\\n ## Figures\\n\\n **Figure 1.** \\n \\n\\n\\n*Page 1 of 6*\",\n \"pagination\": {\n \"current_page\": 1,\n \"total_pages\": 6\n },\n \"questionnaire\": [],\n \"title\": \"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\"\n },\n {\n \"authors\": \"Timothy D. Murphy, MD\",\n \"content\": [\n \"The patient has fallen asleep at school nearly every day for the past 1-2 months and falls into a deep sleep unless she is kept active. At home, she is taking more naps during the day, falling asleep in the car, and struggling with schoolwork. Her grades have dropped significantly over the past few months. Her parents report that she does not awaken during the night. No snoring, choking, snorting, gasping, or apnea is noted. She sleeps an average of 9-10 hours per night but is restless and tosses and turns frequently in her sleep.\",\n \"Her family history is notable for obesity, obstructive sleep apnea (OSA) that requires continuous positive airway pressure (CPAP) in her father, and narcolepsy in an uncle and a grandfather.\",\n \"On physical examination, she has mild to moderate obesity (BMI of 23.89 kg/m2 [the 98th percentile for age]) and enlarged tonsils (2-3+). She has difficulty with focusing and staying awake in the clinic.\",\n \"She is referred to a pediatric otolaryngologist for consideration of nocturnal polysomnography (NPSG) or an adenotonsillectomy. The otolaryngologist notes that she has not tolerated nasal fluticasone well, that she is a chronic mouth breather, and that her tonsils are enlarged (3+). An NPSG is ordered to help clarify matters.\",\n \"The NPSG demonstrates the following:\",\n \"A respiratory disturbance index and an apnea-hypopnea index (AHI) of 6.2 per hour\",\n \"Sleep latency of 0.5 minutes and rapid eye movement (REM) latency of 0.5 minutes\",\n \"A sleep efficiency of 87.5%\",\n \"18.2% of total sleep time in stage N1, 36.4% in N2, 29.9% in N3, and 15.5% in REM sleep\",\n \"An arousal index of 18.6\",\n \"A periodic leg movement index of 6.3\",\n \"Multiple periods of wakefulness scattered throughout the night and six REM periods\"\n ],\n \"date\": \"October 09, 2020\",\n \"figures\": [],\n \"markdown\": \"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\\n\\n **Authors:** Timothy D. Murphy, MD \\n **Date:** October 09, 2020\\n\\n ## Content\\n\\n The patient has fallen asleep at school nearly every day for the past 1-2 months and falls into a deep sleep unless she is kept active. At home, she is taking more naps during the day, falling asleep in the car, and struggling with schoolwork. Her grades have dropped significantly over the past few months. Her parents report that she does not awaken during the night. No snoring, choking, snorting, gasping, or apnea is noted. She sleeps an average of 9-10 hours per night but is restless and tosses and turns frequently in her sleep.\\nHer family history is notable for obesity, obstructive sleep apnea (OSA) that requires continuous positive airway pressure (CPAP) in her father, and narcolepsy in an uncle and a grandfather.\\nOn physical examination, she has mild to moderate obesity (BMI of 23.89 kg/m2 [the 98th percentile for age]) and enlarged tonsils (2-3+). She has difficulty with focusing and staying awake in the clinic.\\nShe is referred to a pediatric otolaryngologist for consideration of nocturnal polysomnography (NPSG) or an adenotonsillectomy. The otolaryngologist notes that she has not tolerated nasal fluticasone well, that she is a chronic mouth breather, and that her tonsils are enlarged (3+). An NPSG is ordered to help clarify matters.\\nThe NPSG demonstrates the following:\\nA respiratory disturbance index and an apnea-hypopnea index (AHI) of 6.2 per hour\\nSleep latency of 0.5 minutes and rapid eye movement (REM) latency of 0.5 minutes\\nA sleep efficiency of 87.5%\\n18.2% of total sleep time in stage N1, 36.4% in N2, 29.9% in N3, and 15.5% in REM sleep\\nAn arousal index of 18.6\\nA periodic leg movement index of 6.3\\nMultiple periods of wakefulness scattered throughout the night and six REM periods\\n\\n ## Figures\\n\\n \\n*Page 2 of 6*\",\n \"pagination\": {\n \"current_page\": 2,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529064,\n \"choiceText\": \"Behavioral insomnia of childhood\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529065,\n \"choiceText\": \"Pediatric chronic obstructive pulmonary disease\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529066,\n \"choiceText\": \"Delayed sleep phase disorder\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529067,\n \"choiceText\": \"Narcolepsy\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490073,\n \"questionText\": \"On the basis of these findings only, what is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\"\n },\n {\n \"authors\": \"Timothy D. Murphy, MD\",\n \"content\": [\n \"This case is very challenging because the patient had the findings of and met the criteria for OSA, periodic limb movement disorder (PLMD)/restless legs syndrome (RLS), and hypersomnolence. She also had several historical findings that were highly suggestive of narcolepsy with cataplexy. These included a strong family history of narcolepsy, a history of the sudden onset of sleep and greatly increased sleep pressure, and rapid weight gain. A critical finding was a nocturnal sleep-onset REM sleep period (SOREMP). A nocturnal SOREMP (defined as REM sleep within 15 minutes of falling asleep) has a very high specificity for narcolepsy with cataplexy in adults and children.[1,2] However, the importance of the nocturnal SOREMP was not initially noted in her evaluation and management.\",\n \"OSA and PLMD were initially diagnosed, and the otolaryngologist performed an adenotonsillectomy. The patient returned to the pediatric pulmonary and sleep medicine clinic after the procedure. At 3 weeks after the surgery, her somnolence improved very little. She had been gaining weight more rapidly and symptoms of apparent instability in her asthma were noted.\",\n \"Further history-taking revealed a complex set of interactions around eating (some involved her father catering to her desire for higher-carbohydrate foods), increased sedentary behavior, and a history suggestive of vocal cord dysfunction. She was having \\\"asthma attacks\\\" characterized by rapid onset with inspiratory stridor and rapid resolution at the onset of activity. Her family was willing to make changes in their diet and to encourage activity, and they sought help for the vocal cord dysfunction from a speech and language pathologist.\",\n \"Despite these measures, her weight gain rapidly progressed and the daytime fatigue and sleepiness continued. The pediatrician referred her to the neurologist who had interpreted the first NPSG. His history presented a differential diagnosis of narcolepsy, primary hypersomnolence, persistent OSA, and PLMD. He recommended a second NPSG with a multiple sleep latency test (MSLT), to be done immediately following the NPSG to assess her sleepiness more formally. His history documented that she felt as if she was \\\"going to fall\\\" when she laughed. He also noted that her father had OSA (treated with CPAP) and that she had an uncle and a grandfather with narcolepsy.\",\n \"The second NPSG revealed the following:\",\n \"A respiratory disturbance index of 1.4 (improved)\",\n \"Sleep latency of 2.5 minutes and REM latency of 68.5 minutes\",\n \"A sleep efficiency of 68.3%\",\n \"31.6% of total sleep time in stage N1, 43.8% in N2, 20% in N3, and 4.6% in REM sleep\",\n \"An arousal index of 23.5 (increased)\",\n \"A periodic leg movement index of 5.9 (slightly lower)\",\n \"\\\"3 REM periods, 2 of them were very brief,\\\" and a period of wakefulness after sleep onset of 180.5 minutes (increased)\",\n \"The MSLT showed a mean sleep latency calculated at 9.5 minutes and no sleep onset–associated REM sleep (REM sleep within 20 minutes of sleep onset).\",\n \"The neurologist provisionally diagnosed narcolepsy (vs hypersomnolence). He prescribed methylphenidate and then gradually increased the dose. Despite slightly improved daytime alertness, the patient started to develop more classic findings of cataplexy. The patient's mother brought her back to the pediatric pulmonary and sleep medicine clinic. Methylphenidate was discontinued and therapy with modafinil was initiated.\",\n \"When the patient was 9 years old, sodium oxybate was added to her regimen and her condition finally stabilized. Her therapy was complicated by the treatment of her inattention with dextroamphetamine and levoamphetamine (Adderall) and the effects of all of her therapy on her weight. Her rapid weight gain was followed by an equally rapid weight loss, and these changes finally settled into her currently stable pattern of tracking around the 75th percentile after starting sodium oxybate (Figure 2).\",\n \"Figure 2.\"\n ],\n \"date\": \"October 09, 2020\",\n \"figures\": [\n {\n \"caption\": \"Figure 2.\",\n \"image_url\": \"https://img.medscapestatic.com/article/938/423/938423-Thumb2.jpg\"\n }\n ],\n \"markdown\": \"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\\n\\n **Authors:** Timothy D. Murphy, MD \\n **Date:** October 09, 2020\\n\\n ## Content\\n\\n This case is very challenging because the patient had the findings of and met the criteria for OSA, periodic limb movement disorder (PLMD)/restless legs syndrome (RLS), and hypersomnolence. She also had several historical findings that were highly suggestive of narcolepsy with cataplexy. These included a strong family history of narcolepsy, a history of the sudden onset of sleep and greatly increased sleep pressure, and rapid weight gain. A critical finding was a nocturnal sleep-onset REM sleep period (SOREMP). A nocturnal SOREMP (defined as REM sleep within 15 minutes of falling asleep) has a very high specificity for narcolepsy with cataplexy in adults and children.[1,2] However, the importance of the nocturnal SOREMP was not initially noted in her evaluation and management.\\nOSA and PLMD were initially diagnosed, and the otolaryngologist performed an adenotonsillectomy. The patient returned to the pediatric pulmonary and sleep medicine clinic after the procedure. At 3 weeks after the surgery, her somnolence improved very little. She had been gaining weight more rapidly and symptoms of apparent instability in her asthma were noted.\\nFurther history-taking revealed a complex set of interactions around eating (some involved her father catering to her desire for higher-carbohydrate foods), increased sedentary behavior, and a history suggestive of vocal cord dysfunction. She was having \\\"asthma attacks\\\" characterized by rapid onset with inspiratory stridor and rapid resolution at the onset of activity. Her family was willing to make changes in their diet and to encourage activity, and they sought help for the vocal cord dysfunction from a speech and language pathologist.\\nDespite these measures, her weight gain rapidly progressed and the daytime fatigue and sleepiness continued. The pediatrician referred her to the neurologist who had interpreted the first NPSG. His history presented a differential diagnosis of narcolepsy, primary hypersomnolence, persistent OSA, and PLMD. He recommended a second NPSG with a multiple sleep latency test (MSLT), to be done immediately following the NPSG to assess her sleepiness more formally. His history documented that she felt as if she was \\\"going to fall\\\" when she laughed. He also noted that her father had OSA (treated with CPAP) and that she had an uncle and a grandfather with narcolepsy.\\nThe second NPSG revealed the following:\\nA respiratory disturbance index of 1.4 (improved)\\nSleep latency of 2.5 minutes and REM latency of 68.5 minutes\\nA sleep efficiency of 68.3%\\n31.6% of total sleep time in stage N1, 43.8% in N2, 20% in N3, and 4.6% in REM sleep\\nAn arousal index of 23.5 (increased)\\nA periodic leg movement index of 5.9 (slightly lower)\\n\\\"3 REM periods, 2 of them were very brief,\\\" and a period of wakefulness after sleep onset of 180.5 minutes (increased)\\nThe MSLT showed a mean sleep latency calculated at 9.5 minutes and no sleep onset–associated REM sleep (REM sleep within 20 minutes of sleep onset).\\nThe neurologist provisionally diagnosed narcolepsy (vs hypersomnolence). He prescribed methylphenidate and then gradually increased the dose. Despite slightly improved daytime alertness, the patient started to develop more classic findings of cataplexy. The patient's mother brought her back to the pediatric pulmonary and sleep medicine clinic. Methylphenidate was discontinued and therapy with modafinil was initiated.\\nWhen the patient was 9 years old, sodium oxybate was added to her regimen and her condition finally stabilized. Her therapy was complicated by the treatment of her inattention with dextroamphetamine and levoamphetamine (Adderall) and the effects of all of her therapy on her weight. Her rapid weight gain was followed by an equally rapid weight loss, and these changes finally settled into her currently stable pattern of tracking around the 75th percentile after starting sodium oxybate (Figure 2).\\nFigure 2.\\n\\n ## Figures\\n\\n **Figure 2.** \\n \\n\\n\\n*Page 3 of 6*\",\n \"pagination\": {\n \"current_page\": 3,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529064,\n \"choiceText\": \"Behavioral insomnia of childhood\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529065,\n \"choiceText\": \"Pediatric chronic obstructive pulmonary disease\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529066,\n \"choiceText\": \"Delayed sleep phase disorder\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529067,\n \"choiceText\": \"Narcolepsy\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490073,\n \"questionText\": \"On the basis of these findings only, what is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\"\n },\n {\n \"authors\": \"Timothy D. Murphy, MD\",\n \"content\": [\n \"This case illustrates some of the challenges facing clinicians who care for a \\\"sleepy child.\\\" In the evolution of this child's care, multiple diagnoses were made and treated. The failure of her symptoms to respond to treatment resulted in further evaluation (and reevaluation of the data), which finally led to the diagnosis (narcolepsy with cataplexy) and her ultimate improvement and stabilization.\",\n \"Hypersomnolence may be primary or it may be secondary to a poor night's sleep. The most common conditions seen in a pediatric sleep clinic that might lead to daytime sleepiness include sleep apnea, behavioral insomnia of childhood, restless sleeping (or, when more extreme, pediatric RLS), and delayed sleep phase disorder (DSPD). The latter is much more common in teenagers, with a prevalence of up to 7% in this age group.[3] However, youths with daytime hypersomnolence due to DSPD do not typically fall asleep easily at bedtime, as this patient did. Moreover, DSPD is unusual in an 8-year-old.\",\n \"An insufficient quantity of sleep can usually be diagnosed on the basis of the history alone, but actigraphy is occasionally used when the history does not exclude difficulty in falling asleep or a circadian rhythm sleep-wake disorder.[4] Actigraphy was not included in this patient's workup.\",\n \"Pediatric RLS is primarily diagnosed on the basis of history, but the use of strict criteria (which include that the child \\\"relates a description in his or her own words\\\" of leg discomfort) may lead to missing the diagnosis in children who can benefit from treatment but are unable to verbalize their feelings. Suboptimal levels of serum ferritin are associated with restless sleep in children, as is improvement with iron therapy. The use of dopaminergic medications typically requires a higher standard for the diagnosis of RLS and a failure to respond to iron therapy.[5,6] Published data regarding autism and attention-deficit/hyperactivity disorder (ADHD) increasingly suggest complex links between iron metabolism and brain function, including during sleep.[7,8] This patient's movements in bed and her behavioral and learning struggles led to the investigation of her iron stores and ferritin levels and a trial of treatment for RLS.\",\n \"Hypersomnolence is associated with OSA more commonly in adults than in children. \\\"Hyperactivity\\\" or symptoms of ADHD are more frequently observed in children with OSA, although some sleepiness is still noted.[9] Most sleep centers consider an obstructive AHI of fewer than 1 event per hour (some use a threshold of 1.5) to be normal.[10] More pragmatically, the absolute score is useful in choosing a diagnostic billing code, but clinical decision-making also factors in the age of the patient and the severity of observed symptoms, considered formally or as a gestalt.[11]\",\n \"This patient had a positive AHI, which is diagnostic of OSA, and underwent adenotonsillectomy without significant improvement. She was also treated with iron and vitamin C, without significant changes in her daytime sleepiness or her apparent sleep quality. Furthermore, her clinical care was complicated by the MSLT result, which documented hypersomnolence but not narcolepsy.\",\n \"The diagnosis of narcolepsy was based primarily on clinical factors. Despite the positive AHI, snoring, leg movements, and low ferritin level, her condition did not improve after the adenotonsillectomy and iron therapy. As her case progressed, she developed more classic symptoms of cataplexy, such as feeling as if she would fall with laughter and falling asleep rapidly in conjunction with strong emotions. These findings, along with the rapid weight gain, pointed toward the diagnosis.\",\n \"Some confusion along the path toward a diagnosis is common in narcolepsy. Comorbidities, including PLMD, RLS, and OSA, may be found in association with narcolepsy and can delay the diagnosis,[12] as certainly happened in this patient.\",\n \"Narcolepsy affects about 1 in 2000 people. Two types are recognized: type 1 narcolepsy (previously referred to as narcolepsy with cataplexy) and type 2 narcolepsy (narcolepsy without cataplexy). Type 1 narcolepsy is considered an adult diagnosis by many pediatricians, but it frequently develops during adolescence, and onset after age 40 years is uncommon. Children may first present with a resumption of prolonged naps rather than prolonged nighttime sleep; nocturnal sleep is often somewhat disturbed initially. Cataplexy, multiple short naps during the day, hypnagogic hallucinations, and sleep-onset REM periods may be absent in young children, and repeated NPSGs and MSLTs over months to years may be required to make the diagnosis.\",\n \"Although a retrospective analysis of sleep histories often reveals hypersomnolence for years prior to the diagnosis, it can be easily missed in the first decade of life.[13] Type 1 narcolepsy is caused by the loss of orexin neuropeptides, which are mediators of central nervous system (CNS) control of energy metabolism and maintenance of sleep-wake states. Rapid weight gain and precocious puberty can occur in children with type 1 narcolepsy. This patient's rapid weight gain started to make more sense once the diagnosis was made.[14]\",\n \"In type 1 narcolepsy, the lack of consistent REM sleep at night leads to the intrusion of REM sleep features into the waking state. The diagnostic features include the tetrad of daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Specific questioning is usually required to elicit the history; only cataplexy is specific for narcolepsy. Patients often present initially with hypersomnolence alone, and other diagnostic findings may emerge over time.\",\n \"The etiology of narcolepsy is unclear. The lack of orexin may be related to autoimmune disease or infectious diseases. Most patients with type 1 narcolepsy have HLA DQB1 (0602 allele), the gene complex that encodes for proteins on the surface of T cells. Additionally, some infections (most notably H1N1 influenza, as well as some vaccines for it) are associated with clusters of type 1 narcolepsy and reduced orexin levels.[15,16,17] However, measurement of cerebrospinal fluid (CSF) levels of orexin is not required to make the diagnosis of narcolepsy.\",\n \"The diagnosis of type 1 narcolepsy can be clinically made in a child with a clear history of cataplexy, EDS, and an otherwise normal neurologic examination. In the absence of cataplexy, an NPSG followed by an MSLT can be used to make the diagnosis of narcolepsy. \\\"Secondary narcolepsy\\\" in the setting of CNS diseases such as hypothalamic tumors or arteriovenous malformations, following cerebrovascular accidents, or in association with multiple sclerosis or Niemann-Pick disease type C has been reported, but alternative causes of narcolepsy are vanishingly rare in childhood. The primary challenge is to rule out other sleep disorders causing the EDS; as in this patient, that may be difficult.\"\n ],\n \"date\": \"October 09, 2020\",\n \"figures\": [],\n \"markdown\": \"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\\n\\n **Authors:** Timothy D. Murphy, MD \\n **Date:** October 09, 2020\\n\\n ## Content\\n\\n This case illustrates some of the challenges facing clinicians who care for a \\\"sleepy child.\\\" In the evolution of this child's care, multiple diagnoses were made and treated. The failure of her symptoms to respond to treatment resulted in further evaluation (and reevaluation of the data), which finally led to the diagnosis (narcolepsy with cataplexy) and her ultimate improvement and stabilization.\\nHypersomnolence may be primary or it may be secondary to a poor night's sleep. The most common conditions seen in a pediatric sleep clinic that might lead to daytime sleepiness include sleep apnea, behavioral insomnia of childhood, restless sleeping (or, when more extreme, pediatric RLS), and delayed sleep phase disorder (DSPD). The latter is much more common in teenagers, with a prevalence of up to 7% in this age group.[3] However, youths with daytime hypersomnolence due to DSPD do not typically fall asleep easily at bedtime, as this patient did. Moreover, DSPD is unusual in an 8-year-old.\\nAn insufficient quantity of sleep can usually be diagnosed on the basis of the history alone, but actigraphy is occasionally used when the history does not exclude difficulty in falling asleep or a circadian rhythm sleep-wake disorder.[4] Actigraphy was not included in this patient's workup.\\nPediatric RLS is primarily diagnosed on the basis of history, but the use of strict criteria (which include that the child \\\"relates a description in his or her own words\\\" of leg discomfort) may lead to missing the diagnosis in children who can benefit from treatment but are unable to verbalize their feelings. Suboptimal levels of serum ferritin are associated with restless sleep in children, as is improvement with iron therapy. The use of dopaminergic medications typically requires a higher standard for the diagnosis of RLS and a failure to respond to iron therapy.[5,6] Published data regarding autism and attention-deficit/hyperactivity disorder (ADHD) increasingly suggest complex links between iron metabolism and brain function, including during sleep.[7,8] This patient's movements in bed and her behavioral and learning struggles led to the investigation of her iron stores and ferritin levels and a trial of treatment for RLS.\\nHypersomnolence is associated with OSA more commonly in adults than in children. \\\"Hyperactivity\\\" or symptoms of ADHD are more frequently observed in children with OSA, although some sleepiness is still noted.[9] Most sleep centers consider an obstructive AHI of fewer than 1 event per hour (some use a threshold of 1.5) to be normal.[10] More pragmatically, the absolute score is useful in choosing a diagnostic billing code, but clinical decision-making also factors in the age of the patient and the severity of observed symptoms, considered formally or as a gestalt.[11]\\nThis patient had a positive AHI, which is diagnostic of OSA, and underwent adenotonsillectomy without significant improvement. She was also treated with iron and vitamin C, without significant changes in her daytime sleepiness or her apparent sleep quality. Furthermore, her clinical care was complicated by the MSLT result, which documented hypersomnolence but not narcolepsy.\\nThe diagnosis of narcolepsy was based primarily on clinical factors. Despite the positive AHI, snoring, leg movements, and low ferritin level, her condition did not improve after the adenotonsillectomy and iron therapy. As her case progressed, she developed more classic symptoms of cataplexy, such as feeling as if she would fall with laughter and falling asleep rapidly in conjunction with strong emotions. These findings, along with the rapid weight gain, pointed toward the diagnosis.\\nSome confusion along the path toward a diagnosis is common in narcolepsy. Comorbidities, including PLMD, RLS, and OSA, may be found in association with narcolepsy and can delay the diagnosis,[12] as certainly happened in this patient.\\nNarcolepsy affects about 1 in 2000 people. Two types are recognized: type 1 narcolepsy (previously referred to as narcolepsy with cataplexy) and type 2 narcolepsy (narcolepsy without cataplexy). Type 1 narcolepsy is considered an adult diagnosis by many pediatricians, but it frequently develops during adolescence, and onset after age 40 years is uncommon. Children may first present with a resumption of prolonged naps rather than prolonged nighttime sleep; nocturnal sleep is often somewhat disturbed initially. Cataplexy, multiple short naps during the day, hypnagogic hallucinations, and sleep-onset REM periods may be absent in young children, and repeated NPSGs and MSLTs over months to years may be required to make the diagnosis.\\nAlthough a retrospective analysis of sleep histories often reveals hypersomnolence for years prior to the diagnosis, it can be easily missed in the first decade of life.[13] Type 1 narcolepsy is caused by the loss of orexin neuropeptides, which are mediators of central nervous system (CNS) control of energy metabolism and maintenance of sleep-wake states. Rapid weight gain and precocious puberty can occur in children with type 1 narcolepsy. This patient's rapid weight gain started to make more sense once the diagnosis was made.[14]\\nIn type 1 narcolepsy, the lack of consistent REM sleep at night leads to the intrusion of REM sleep features into the waking state. The diagnostic features include the tetrad of daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Specific questioning is usually required to elicit the history; only cataplexy is specific for narcolepsy. Patients often present initially with hypersomnolence alone, and other diagnostic findings may emerge over time.\\nThe etiology of narcolepsy is unclear. The lack of orexin may be related to autoimmune disease or infectious diseases. Most patients with type 1 narcolepsy have HLA DQB1 (0602 allele), the gene complex that encodes for proteins on the surface of T cells. Additionally, some infections (most notably H1N1 influenza, as well as some vaccines for it) are associated with clusters of type 1 narcolepsy and reduced orexin levels.[15,16,17] However, measurement of cerebrospinal fluid (CSF) levels of orexin is not required to make the diagnosis of narcolepsy.\\nThe diagnosis of type 1 narcolepsy can be clinically made in a child with a clear history of cataplexy, EDS, and an otherwise normal neurologic examination. In the absence of cataplexy, an NPSG followed by an MSLT can be used to make the diagnosis of narcolepsy. \\\"Secondary narcolepsy\\\" in the setting of CNS diseases such as hypothalamic tumors or arteriovenous malformations, following cerebrovascular accidents, or in association with multiple sclerosis or Niemann-Pick disease type C has been reported, but alternative causes of narcolepsy are vanishingly rare in childhood. The primary challenge is to rule out other sleep disorders causing the EDS; as in this patient, that may be difficult.\\n\\n ## Figures\\n\\n \\n*Page 4 of 6*\",\n \"pagination\": {\n \"current_page\": 4,\n \"total_pages\": 6\n },\n \"questionnaire\": [],\n \"title\": \"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\"\n },\n {\n \"authors\": \"Timothy D. Murphy, MD\",\n \"content\": [\n \"The treatment of narcolepsy focuses first on attempts to reduce the EDS pharmacologically; timed naps or increased time in bed is not usually sufficient to reduce the EDS. Although many medications have been used to treat EDS, clinicians typically start with caffeine (usually inadequate) and then move to stronger stimulants, such as methylphenidate or amphetamine and dextroamphetamine in combination.\",\n \"Failure of these agents might then lead to the use of modafinil (prescription without the failure of other therapies is often difficult). Monitoring of response and fairly frequent visits are required at this point. A selective serotonin reuptake inhibitor, such as fluoxetine, is often added to the regimen of patients with classic cataplexy. As was the case for this patient, the use of medications that might affect mood, attention, learning, and sleep requires close attention and collaboration between specialists in sleep medicine, neurology, and behavioral and general pediatrics.\",\n \"In some patients, including this patient, sodium oxybate (gamma-hydroxybutyrate [GHB]) is required to treat the cataplexy and to lead to better daytime functioning.[18] The exact mechanism of action is unknown, but the evening dosing of GHB is associated with improved REM sleep at night, perhaps relieving the intrusion of REM during daytime wake periods associated with type 1 narcolepsy. Unfortunately, GHB is associated with abuse — it is often called the \\\"date rape drug\\\" — and is now tightly regulated. Prescription in the United States is limited to one US pharmacy, and a sleep physician is typically required to obtain and use this medication.\",\n \"The finding of EDS requires exploration of nocturnal problems with sleep, including RLS, OSA, and behavioral insomnia that affects daytime functioning. Narcolepsy can be diagnosed as the cause of EDS on the basis of careful history-taking as well as the results of an NPSG and an MSLT.\"\n ],\n \"date\": \"October 09, 2020\",\n \"figures\": [],\n \"markdown\": \"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\\n\\n **Authors:** Timothy D. Murphy, MD \\n **Date:** October 09, 2020\\n\\n ## Content\\n\\n The treatment of narcolepsy focuses first on attempts to reduce the EDS pharmacologically; timed naps or increased time in bed is not usually sufficient to reduce the EDS. Although many medications have been used to treat EDS, clinicians typically start with caffeine (usually inadequate) and then move to stronger stimulants, such as methylphenidate or amphetamine and dextroamphetamine in combination.\\nFailure of these agents might then lead to the use of modafinil (prescription without the failure of other therapies is often difficult). Monitoring of response and fairly frequent visits are required at this point. A selective serotonin reuptake inhibitor, such as fluoxetine, is often added to the regimen of patients with classic cataplexy. As was the case for this patient, the use of medications that might affect mood, attention, learning, and sleep requires close attention and collaboration between specialists in sleep medicine, neurology, and behavioral and general pediatrics.\\nIn some patients, including this patient, sodium oxybate (gamma-hydroxybutyrate [GHB]) is required to treat the cataplexy and to lead to better daytime functioning.[18] The exact mechanism of action is unknown, but the evening dosing of GHB is associated with improved REM sleep at night, perhaps relieving the intrusion of REM during daytime wake periods associated with type 1 narcolepsy. Unfortunately, GHB is associated with abuse — it is often called the \\\"date rape drug\\\" — and is now tightly regulated. Prescription in the United States is limited to one US pharmacy, and a sleep physician is typically required to obtain and use this medication.\\nThe finding of EDS requires exploration of nocturnal problems with sleep, including RLS, OSA, and behavioral insomnia that affects daytime functioning. Narcolepsy can be diagnosed as the cause of EDS on the basis of careful history-taking as well as the results of an NPSG and an MSLT.\\n\\n ## Figures\\n\\n \\n*Page 5 of 6*\",\n \"pagination\": {\n \"current_page\": 5,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529068,\n \"choiceText\": \"Narcolepsy without cataplexy (type 2 narcolepsy) is associated with increased orexin neuropeptide levels\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529069,\n \"choiceText\": \"Childhood narcolepsy is characterized by multiple brief naps during the day\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529070,\n \"choiceText\": \"Narcolepsy is associated with the loss of orexin neuropeptides\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529071,\n \"choiceText\": \"Measurement of orexin levels in the CSF is required for the diagnosis of narcolepsy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Levels of orexin neuropeptides in the CNS are reduced, not increased, in all forms of narcolepsy. Children more frequently present with prolonged daytime sleep, and multiple naps are typically seen in older patients. The diagnosis can be made by a careful history-taking that documents cataplexy, which is explained only by type 1 narcolepsy. Measurement of CSF levels of orexin is usually related to research only and typically is not used clinically in diagnosing narcolepsy.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490074,\n \"questionText\": \"Which of the following is most accurate regarding narcolepsy in children?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529072,\n \"choiceText\": \"Timed or planned naps to reduce sleep pressure, and amphetamine and dextroamphetamine for stimulant therapy during the day\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529073,\n \"choiceText\": \"Modafinil as a daytime stimulant, fluoxetine for cataplexy, and sodium oxybate to improve REM efficiency\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529074,\n \"choiceText\": \"Caffeine as a morning stimulant and sodium oxybate (gamma-hydroxybutyrate [GHB]) used at night to consolidate non-REM sleep\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529075,\n \"choiceText\": \"Methylphenidate to reduce cataplexy, fluoxetine to reduce depressive symptoms, and sodium oxybate to prolong REM latency\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Caffeine is usually an inadequate stimulant for patients with narcolepsy. The daytime use of methylphenidate or amphetamine and dextroamphetamine in combination does not adequately reduce cataplexy and does not address the problem with REM sleep at night. Modafinil is a more reliable daytime stimulant, and fluoxetine helps reduce cataplexy. The use of sodium oxybate in the evening in divided doses is intended to consolidate REM sleep and may reduce REM latency; non-REM sleep is not related to the daytime difficulties associated with narcolepsy.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490075,\n \"questionText\": \"Which of the following is typically required in the treatment of type 1 narcolepsy?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\"\n },\n {\n \"authors\": \"Timothy D. Murphy, MD\",\n \"content\": [],\n \"date\": \"October 09, 2020\",\n \"figures\": [],\n \"markdown\": \"# Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\\n\\n **Authors:** Timothy D. Murphy, MD \\n **Date:** October 09, 2020\\n\\n ## Content\\n\\n \\n\\n ## Figures\\n\\n \\n*Page 6 of 6*\",\n \"pagination\": {\n \"current_page\": 6,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529068,\n \"choiceText\": \"Narcolepsy without cataplexy (type 2 narcolepsy) is associated with increased orexin neuropeptide levels\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529069,\n \"choiceText\": \"Childhood narcolepsy is characterized by multiple brief naps during the day\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529070,\n \"choiceText\": \"Narcolepsy is associated with the loss of orexin neuropeptides\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529071,\n \"choiceText\": \"Measurement of orexin levels in the CSF is required for the diagnosis of narcolepsy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Levels of orexin neuropeptides in the CNS are reduced, not increased, in all forms of narcolepsy. Children more frequently present with prolonged daytime sleep, and multiple naps are typically seen in older patients. The diagnosis can be made by a careful history-taking that documents cataplexy, which is explained only by type 1 narcolepsy. Measurement of CSF levels of orexin is usually related to research only and typically is not used clinically in diagnosing narcolepsy.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490074,\n \"questionText\": \"Which of the following is most accurate regarding narcolepsy in children?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529072,\n \"choiceText\": \"Timed or planned naps to reduce sleep pressure, and amphetamine and dextroamphetamine for stimulant therapy during the day\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529073,\n \"choiceText\": \"Modafinil as a daytime stimulant, fluoxetine for cataplexy, and sodium oxybate to improve REM efficiency\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529074,\n \"choiceText\": \"Caffeine as a morning stimulant and sodium oxybate (gamma-hydroxybutyrate [GHB]) used at night to consolidate non-REM sleep\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529075,\n \"choiceText\": \"Methylphenidate to reduce cataplexy, fluoxetine to reduce depressive symptoms, and sodium oxybate to prolong REM latency\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Caffeine is usually an inadequate stimulant for patients with narcolepsy. The daytime use of methylphenidate or amphetamine and dextroamphetamine in combination does not adequately reduce cataplexy and does not address the problem with REM sleep at night. Modafinil is a more reliable daytime stimulant, and fluoxetine helps reduce cataplexy. The use of sodium oxybate in the evening in divided doses is intended to consolidate REM sleep and may reduce REM latency; non-REM sleep is not related to the daytime difficulties associated with narcolepsy.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490075,\n \"questionText\": \"Which of the following is typically required in the treatment of type 1 narcolepsy?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Rapid Weight Gain in an Excessively Sleepy Girl With Asthma\"\n }\n]","isConversational":false},"questions":{"kind":"list like","value":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529064,"choiceText":"Behavioral insomnia of childhood\r\n","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529065,"choiceText":"Pediatric chronic obstructive pulmonary disease","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529066,"choiceText":"Delayed sleep phase disorder","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529067,"choiceText":"Narcolepsy","correct":true,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490073,"questionText":"On the basis of these findings only, what is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529068,"choiceText":"Narcolepsy without cataplexy (type 2 narcolepsy) is associated with increased orexin neuropeptide levels","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529069,"choiceText":"Childhood narcolepsy is characterized by multiple brief naps during the day","correct":false,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529070,"choiceText":"Narcolepsy is associated with the loss of orexin neuropeptides","correct":true,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529071,"choiceText":"Measurement of orexin levels in the CSF is required for the diagnosis of narcolepsy","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Levels of orexin neuropeptides in the CNS are reduced, not increased, in all forms of narcolepsy. Children more frequently present with prolonged daytime sleep, and multiple naps are typically seen in older patients. The diagnosis can be made by a careful history-taking that documents cataplexy, which is explained only by type 1 narcolepsy. Measurement of CSF levels of orexin is usually related to research only and typically is not used clinically in diagnosing narcolepsy.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490074,"questionText":"Which of the following is most accurate regarding narcolepsy in children?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1529072,"choiceText":"Timed or planned naps to reduce sleep pressure, and amphetamine and dextroamphetamine for stimulant therapy during the day\r\n","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529073,"choiceText":"Modafinil as a daytime stimulant, fluoxetine for cataplexy, and sodium oxybate to improve REM efficiency","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529074,"choiceText":"Caffeine as a morning stimulant and sodium oxybate (gamma-hydroxybutyrate [GHB]) used at night to consolidate non-REM sleep","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1529075,"choiceText":"Methylphenidate to reduce cataplexy, fluoxetine to reduce depressive symptoms, and sodium oxybate to prolong REM latency","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Caffeine is usually an inadequate stimulant for patients with narcolepsy. The daytime use of methylphenidate or amphetamine and dextroamphetamine in combination does not adequately reduce cataplexy and does not address the problem with REM sleep at night. Modafinil is a more reliable daytime stimulant, and fluoxetine helps reduce cataplexy. The use of sodium oxybate in the evening in divided doses is intended to consolidate REM sleep and may reduce REM latency; non-REM sleep is not related to the daytime difficulties associated with narcolepsy.","displayOrder":3,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":490075,"questionText":"Which of the following is typically required in the treatment of type 1 narcolepsy?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"string":"[\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529064,\n \"choiceText\": \"Behavioral insomnia of childhood\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529065,\n \"choiceText\": \"Pediatric chronic obstructive pulmonary disease\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529066,\n \"choiceText\": \"Delayed sleep phase disorder\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529067,\n \"choiceText\": \"Narcolepsy\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490073,\n \"questionText\": \"On the basis of these findings only, what is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529068,\n \"choiceText\": \"Narcolepsy without cataplexy (type 2 narcolepsy) is associated with increased orexin neuropeptide levels\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529069,\n \"choiceText\": \"Childhood narcolepsy is characterized by multiple brief naps during the day\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529070,\n \"choiceText\": \"Narcolepsy is associated with the loss of orexin neuropeptides\",\n \"correct\": true,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529071,\n \"choiceText\": \"Measurement of orexin levels in the CSF is required for the diagnosis of narcolepsy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Levels of orexin neuropeptides in the CNS are reduced, not increased, in all forms of narcolepsy. Children more frequently present with prolonged daytime sleep, and multiple naps are typically seen in older patients. The diagnosis can be made by a careful history-taking that documents cataplexy, which is explained only by type 1 narcolepsy. Measurement of CSF levels of orexin is usually related to research only and typically is not used clinically in diagnosing narcolepsy.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490074,\n \"questionText\": \"Which of the following is most accurate regarding narcolepsy in children?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1529072,\n \"choiceText\": \"Timed or planned naps to reduce sleep pressure, and amphetamine and dextroamphetamine for stimulant therapy during the day\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529073,\n \"choiceText\": \"Modafinil as a daytime stimulant, fluoxetine for cataplexy, and sodium oxybate to improve REM efficiency\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529074,\n \"choiceText\": \"Caffeine as a morning stimulant and sodium oxybate (gamma-hydroxybutyrate [GHB]) used at night to consolidate non-REM sleep\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1529075,\n \"choiceText\": \"Methylphenidate to reduce cataplexy, fluoxetine to reduce depressive symptoms, and sodium oxybate to prolong REM latency\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Caffeine is usually an inadequate stimulant for patients with narcolepsy. The daytime use of methylphenidate or amphetamine and dextroamphetamine in combination does not adequately reduce cataplexy and does not address the problem with REM sleep at night. Modafinil is a more reliable daytime stimulant, and fluoxetine helps reduce cataplexy. The use of sodium oxybate in the evening in divided doses is intended to consolidate REM sleep and may reduce REM latency; non-REM sleep is not related to the daytime difficulties associated with narcolepsy.\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 490075,\n \"questionText\": \"Which of the following is typically required in the treatment of type 1 narcolepsy?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n]","isConversational":false}}},{"rowIdx":299,"cells":{"article_id":{"kind":"string","value":"904350"},"url":{"kind":"string","value":"/viewarticle/904350"},"article_data":{"kind":"list like","value":[{"authors":"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO","content":["Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.","A 49-year-old man with a significant medical history of alcohol abuse, tobacco dependence, and pancreatitis presents to the emergency department (ED) with abdominal pain that has lasted for 3 days. The abdominal pain has been intermittent, achy, and located in the periumbilical region. Associated symptoms have included nausea and vomiting, with several episodes of watery, brown diarrhea.","The patient reports a history of alcohol abuse, stating that he has ingested at least 1 pint a day since he was a teenager. He states that this pain feels different from the pain associated with his last bout of pancreatitis."],"date":"October 02, 2020","figures":[],"markdown":"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\n\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \n **Date:** October 02, 2020\n\n ## Content\n\n Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.\nA 49-year-old man with a significant medical history of alcohol abuse, tobacco dependence, and pancreatitis presents to the emergency department (ED) with abdominal pain that has lasted for 3 days. The abdominal pain has been intermittent, achy, and located in the periumbilical region. Associated symptoms have included nausea and vomiting, with several episodes of watery, brown diarrhea.\nThe patient reports a history of alcohol abuse, stating that he has ingested at least 1 pint a day since he was a teenager. He states that this pain feels different from the pain associated with his last bout of pancreatitis.\n\n ## Figures\n\n \n*Page 1 of 6*","pagination":{"current_page":1,"total_pages":6},"questionnaire":[],"title":"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old"},{"authors":"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO","content":["Upon arrival to the ED, the patient has a temperature of 97.9°F (36.6°C), a heart rate of 91 beats/min, a respiratory rate of 23 breaths/min, blood pressure of 113/85 mm Hg, and 98% saturation on room air.","Upon physical examination, he appears uncomfortable and is lying on his right side; he is slightly diaphoretic, with dry oral mucosa. Abdominal examination reveals a soft abdomen with apparent tenderness to palpation in the epigastric and periumbilical region, with minimal left upper-quadrant pain. His abdominal pain appears out of proportion to the physical examination findings.","His laboratory values are as follows:","White blood cell count: 13,000 cells/µL (reference range, 4,000-11,000 cells/µL)","Hemoglobin level: 14.1 g/dL (reference range, 13.5-17.5 g/dL)","Hematocrit: 39% (reference range, 41%-50%)","Platelet count: 506,000 cells/µL (reference range, 150,000-400,000 cells/µL)","Aspartate aminotransferase level: 126 U/L (reference range, 6-34 IU/L)","Alanine aminotransferase level: 81 U/L (reference range, 7-55 U/L)","Amylase level: 125 U/L (reference range, 30-110 U/L)","Lipase level: 419 U/L (reference range, 0-160 U/L)","Gamma glutamyltransferase level: 58 U/L (reference range, 8-38 U/L)","Lactate dehydrogenase level: 175 U/L (reference range, 140-280 U/L)","Lactic acid level: 0.7 mmol/L (reference range, 0.5-2.2 mmol/L)","Glucose level: 102 mg/dL (reference range, <100 mg/dL)","Rectal examination findings are negative for occult blood. All other laboratory values are unremarkable, including alcohol level. Subsequent CT of the abdomen/pelvis with intravenous contrast was performed (Figures 1-3).","Figure 1.","Figure 2.","Figure 3."],"date":"October 02, 2020","figures":[{"caption":"Figure 1.","image_url":"https://img.medscapestatic.com/article/904/350/904350-Thumb1.png"},{"caption":"Figure 2.","image_url":"https://img.medscapestatic.com/article/904/350/904350-Thumb2.png"},{"caption":"Figure 3.","image_url":"https://img.medscapestatic.com/article/904/350/904350-Thumb3.png"}],"markdown":"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\n\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \n **Date:** October 02, 2020\n\n ## Content\n\n Upon arrival to the ED, the patient has a temperature of 97.9°F (36.6°C), a heart rate of 91 beats/min, a respiratory rate of 23 breaths/min, blood pressure of 113/85 mm Hg, and 98% saturation on room air.\nUpon physical examination, he appears uncomfortable and is lying on his right side; he is slightly diaphoretic, with dry oral mucosa. Abdominal examination reveals a soft abdomen with apparent tenderness to palpation in the epigastric and periumbilical region, with minimal left upper-quadrant pain. His abdominal pain appears out of proportion to the physical examination findings.\nHis laboratory values are as follows:\nWhite blood cell count: 13,000 cells/µL (reference range, 4,000-11,000 cells/µL)\nHemoglobin level: 14.1 g/dL (reference range, 13.5-17.5 g/dL)\nHematocrit: 39% (reference range, 41%-50%)\nPlatelet count: 506,000 cells/µL (reference range, 150,000-400,000 cells/µL)\nAspartate aminotransferase level: 126 U/L (reference range, 6-34 IU/L)\nAlanine aminotransferase level: 81 U/L (reference range, 7-55 U/L)\nAmylase level: 125 U/L (reference range, 30-110 U/L)\nLipase level: 419 U/L (reference range, 0-160 U/L)\nGamma glutamyltransferase level: 58 U/L (reference range, 8-38 U/L)\nLactate dehydrogenase level: 175 U/L (reference range, 140-280 U/L)\nLactic acid level: 0.7 mmol/L (reference range, 0.5-2.2 mmol/L)\nGlucose level: 102 mg/dL (reference range, <100 mg/dL)\nRectal examination findings are negative for occult blood. All other laboratory values are unremarkable, including alcohol level. Subsequent CT of the abdomen/pelvis with intravenous contrast was performed (Figures 1-3).\nFigure 1.\nFigure 2.\nFigure 3.\n\n ## Figures\n\n **Figure 1.** \n \n\n**Figure 2.** \n \n\n**Figure 3.** \n \n\n\n*Page 2 of 6*","pagination":{"current_page":2,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281940,"choiceText":"Splenic vein thrombosis","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281942,"choiceText":"Superior mesenteric vein thrombosis","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281944,"choiceText":"Mesenteric arterial thrombosis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281946,"choiceText":"Septic pylephlebitis\r\n","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408509,"questionText":"Based only on these findings, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old"},{"authors":"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO","content":["Acute mesenteric vein thrombosis (MVT) is a rare but extremely important cause of mesenteric intestinal ischemia. In this patient, CT of the abdomen/pelvis with intravenous contrast revealed a filling defect that was consistent with acute thrombosis within the superior mesenteric vein (SMV), which extends approximately 3 cm cephalad to the portosplenic confluence. Other associated findings on these images included peripancreatic fat stranding and peripancreatic fluid consistent with acute pancreatitis (Figures 1-3).","Figure 1.","Figure 2.","Figure 3.","Pancreatitis results in a vast spectrum of both arterial and venous complications. The vascular complications involved in pancreatitis are major causes of morbidity and mortality. The venous complications result from thrombosis of the splenic vein and, less commonly, the portal vein and the SMV, as seen in the patient in this case. Prompt recognition is of paramount importance and requires a high index of clinical suspicion because aggressive therapy and anticoagulation can limit progression of the potential devastating consequences.","Patients with acute pancreatitis can present with portal vein thrombosis, splenic vein thrombosis, or (less commonly) superior MVT. Clinical research has shown that an isolated venous thrombosis to only the SMV, without simultaneous involvement of either the portal vein or the splenic vein, is rare. This vascular complication is important because of the increased risk for mesenteric ischemia and bowel infarction if not recognized.[1]","MVT is considered a rare condition, with only 1 case per 5000-15000 inpatient admissions per year; it accounts for roughly 6%-9% of all cases of acute mesenteric ischemia.[2] In a systematic review of 3692 patients from 1966 to 2002, MVT was the cause of acute mesenteric ischemia in about 3% of patients.[3]"],"date":"October 02, 2020","figures":[{"caption":"Figure 1.","image_url":"https://img.medscapestatic.com/article/904/350/904350-Thumb1.png"},{"caption":"Figure 2.","image_url":"https://img.medscapestatic.com/article/904/350/904350-Thumb2.png"},{"caption":"Figure 3.","image_url":"https://img.medscapestatic.com/article/904/350/904350-Thumb3.png"}],"markdown":"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\n\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \n **Date:** October 02, 2020\n\n ## Content\n\n Acute mesenteric vein thrombosis (MVT) is a rare but extremely important cause of mesenteric intestinal ischemia. In this patient, CT of the abdomen/pelvis with intravenous contrast revealed a filling defect that was consistent with acute thrombosis within the superior mesenteric vein (SMV), which extends approximately 3 cm cephalad to the portosplenic confluence. Other associated findings on these images included peripancreatic fat stranding and peripancreatic fluid consistent with acute pancreatitis (Figures 1-3).\nFigure 1.\nFigure 2.\nFigure 3.\nPancreatitis results in a vast spectrum of both arterial and venous complications. The vascular complications involved in pancreatitis are major causes of morbidity and mortality. The venous complications result from thrombosis of the splenic vein and, less commonly, the portal vein and the SMV, as seen in the patient in this case. Prompt recognition is of paramount importance and requires a high index of clinical suspicion because aggressive therapy and anticoagulation can limit progression of the potential devastating consequences.\nPatients with acute pancreatitis can present with portal vein thrombosis, splenic vein thrombosis, or (less commonly) superior MVT. Clinical research has shown that an isolated venous thrombosis to only the SMV, without simultaneous involvement of either the portal vein or the splenic vein, is rare. This vascular complication is important because of the increased risk for mesenteric ischemia and bowel infarction if not recognized.[1]\nMVT is considered a rare condition, with only 1 case per 5000-15000 inpatient admissions per year; it accounts for roughly 6%-9% of all cases of acute mesenteric ischemia.[2] In a systematic review of 3692 patients from 1966 to 2002, MVT was the cause of acute mesenteric ischemia in about 3% of patients.[3]\n\n ## Figures\n\n **Figure 1.** \n \n\n**Figure 2.** \n \n\n**Figure 3.** \n \n\n\n*Page 3 of 6*","pagination":{"current_page":3,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281940,"choiceText":"Splenic vein thrombosis","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281942,"choiceText":"Superior mesenteric vein thrombosis","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281944,"choiceText":"Mesenteric arterial thrombosis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281946,"choiceText":"Septic pylephlebitis\r\n","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408509,"questionText":"Based only on these findings, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old"},{"authors":"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO","content":["Many risk factors for MVT are recognized, including direct injury (eg, abdominal trauma, splenectomy, intra-abdominal inflammatory processes), venous congestion/stasis (eg, congestive heart failure, portal hypertension, cirrhosis), and hypercoagulable conditions (eg, protein C/S deficiency, antithrombin III deficiency, factor V Leiden mutation, pancreatic/colon carcinoma, oral contraceptive use, polycythemia vera, heparin-induced thrombocytopenia, lupus anticoagulant/anti-phospholipid syndrome).[4] In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.[5]","Acute occlusion of the mesenteric vein results in increased resistance within the mesenteric venous bed, leading to decreased perfusion pressure.[3] As flow stagnates in the mesenteric vein, increased venous pressure results in an efflux of fluid into the tissues, leading to bowel-wall edema. If the clinical progression continues, venous return from the bowel wall is completely occluded, and the end result is bowel ischemia.[3] Integrity of the bowel mucosa is lost and bacteria can translocate, leading to lactic acidosis, sepsis, multiorgan failure, and eventually death.[2]","MVT can occur acutely, subacutely, or chronically. The clinical features vary, depending on the location of the thrombus within the splanchnic vasculature.[3] Acute MVT, similar to other forms of acute mesenteric ischemia, presents most often as a colicky periumbilical pain that is often out of proportion to the physical examination findings. However, the onset of venous thrombosis, compared with arterial thrombosis, is often less sudden and dull, with as many as 75% of patients presenting after 2 days of abdominal pain.[3]","Alternatively, chronic mesenteric venous thrombosis often presents with portal hypertension and variceal hemorrhage.[2] In general, peritoneal signs are absent, unless the venous thrombosis goes untreated and the bowel becomes ischemic, in which case peritoneal signs develop.","In a retrospective study, 31 patients diagnosed with MVT from 1985-1999 were reviewed.[4] Approximately 84% of patients presented with abdominal pain, with 16% presenting with peritoneal signs. Common overall symptoms included diarrhea (42%), nausea and vomiting (32%), lower gastrointestinal bleeding (19%), fatigue (16%), and upper gastrointestinal bleeding (10%). Furthermore, only 22 patients were initially treated with heparin. Five patients were found to have peritonitis and underwent exploratory laparotomy, with the ultimate goal to prevent or limit gangrenous bowel, with an additional five patients later undergoing surgery for the development of ischemic bowel. Seven of the 31 patients died within 30 days, secondary to complications from infarcted bowel and multisystemic organ failure. Overall, 19 of the 24 survivors were treated with long-term anticoagulation, with 88% of those surviving long-term.","Differentiating between ischemia secondary to MVT and ischemia secondary to a mesenteric arterial thrombosis is important. MVT presents in the setting of thrombophilia or an inflammatory abdominal process, whereas mesenteric arterial ischemia presents in the setting of cardiac disease, low-flow states, and atrial fibrillation.[1] Similar to all forms of mesenteric ischemia, no clinical features are specific to MVT. As such, a clinician must have a high index of suspicion in order to make an early diagnosis and avoid the complications of an undiagnosed MVT."],"date":"October 02, 2020","figures":[],"markdown":"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\n\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \n **Date:** October 02, 2020\n\n ## Content\n\n Many risk factors for MVT are recognized, including direct injury (eg, abdominal trauma, splenectomy, intra-abdominal inflammatory processes), venous congestion/stasis (eg, congestive heart failure, portal hypertension, cirrhosis), and hypercoagulable conditions (eg, protein C/S deficiency, antithrombin III deficiency, factor V Leiden mutation, pancreatic/colon carcinoma, oral contraceptive use, polycythemia vera, heparin-induced thrombocytopenia, lupus anticoagulant/anti-phospholipid syndrome).[4] In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.[5]\nAcute occlusion of the mesenteric vein results in increased resistance within the mesenteric venous bed, leading to decreased perfusion pressure.[3] As flow stagnates in the mesenteric vein, increased venous pressure results in an efflux of fluid into the tissues, leading to bowel-wall edema. If the clinical progression continues, venous return from the bowel wall is completely occluded, and the end result is bowel ischemia.[3] Integrity of the bowel mucosa is lost and bacteria can translocate, leading to lactic acidosis, sepsis, multiorgan failure, and eventually death.[2]\nMVT can occur acutely, subacutely, or chronically. The clinical features vary, depending on the location of the thrombus within the splanchnic vasculature.[3] Acute MVT, similar to other forms of acute mesenteric ischemia, presents most often as a colicky periumbilical pain that is often out of proportion to the physical examination findings. However, the onset of venous thrombosis, compared with arterial thrombosis, is often less sudden and dull, with as many as 75% of patients presenting after 2 days of abdominal pain.[3]\nAlternatively, chronic mesenteric venous thrombosis often presents with portal hypertension and variceal hemorrhage.[2] In general, peritoneal signs are absent, unless the venous thrombosis goes untreated and the bowel becomes ischemic, in which case peritoneal signs develop.\nIn a retrospective study, 31 patients diagnosed with MVT from 1985-1999 were reviewed.[4] Approximately 84% of patients presented with abdominal pain, with 16% presenting with peritoneal signs. Common overall symptoms included diarrhea (42%), nausea and vomiting (32%), lower gastrointestinal bleeding (19%), fatigue (16%), and upper gastrointestinal bleeding (10%). Furthermore, only 22 patients were initially treated with heparin. Five patients were found to have peritonitis and underwent exploratory laparotomy, with the ultimate goal to prevent or limit gangrenous bowel, with an additional five patients later undergoing surgery for the development of ischemic bowel. Seven of the 31 patients died within 30 days, secondary to complications from infarcted bowel and multisystemic organ failure. Overall, 19 of the 24 survivors were treated with long-term anticoagulation, with 88% of those surviving long-term.\nDifferentiating between ischemia secondary to MVT and ischemia secondary to a mesenteric arterial thrombosis is important. MVT presents in the setting of thrombophilia or an inflammatory abdominal process, whereas mesenteric arterial ischemia presents in the setting of cardiac disease, low-flow states, and atrial fibrillation.[1] Similar to all forms of mesenteric ischemia, no clinical features are specific to MVT. As such, a clinician must have a high index of suspicion in order to make an early diagnosis and avoid the complications of an undiagnosed MVT.\n\n ## Figures\n\n \n*Page 4 of 6*","pagination":{"current_page":4,"total_pages":6},"questionnaire":[],"title":"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old"},{"authors":"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO","content":["Treatment for MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal exams. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence. If evidence of clinical deterioration and bowel infarction is present, surgical intervention is necessary. Broad-spectrum antibiotics are generally reserved for the setting of pylephlebitis, septic thrombophlebitis, and sepsis secondary to bacterial translocation from an infarcted bowel.[2]","Initiation of anticoagulation remains the cornerstone of treatment and should not be delayed.[6]Research has shown that once a patient is transitioned to oral anticoagulation, treatment should continue for 3-6 months, unless a thrombophilia has been diagnosed. After anticoagulation, most MVTs partially or completely recanalize, with one study showing recanalization in 80% of patients who received anticoagulation.[7] However, the recurrence rate has been reported at 15%.","Acute MVT carries a better prognosis than acute mesenteric ischemia. In one systematic review of nearly 3700 cases of acute mesenteric ischemia from 1966 to 2002, the mortality rate of those patients with MVT was 44%, compared with as much as 89% for those patients with advancement to mesenteric ischemia.[8] However, with increasing physician awareness, the use of contrast-enhanced CT to investigate abdominal pain in combination with anticoagulation has improved outcomes in these patients. In more modern studies, the mortality rate of acute MVT is down to 20%, with the most common cause of death being sepsis and multiorgan failure.[8]","In conclusion, acute superior MVT is a rare but important cause of mesenteric intestinal ischemia. It requires a high index of clinical suspicion. Rapid recognition and aggressive therapy are of extreme importance in order to prevent ischemic and infarcted bowel, sepsis, multiorgan failure, and eventual death. The 49-year-old man in this case had nonnecrotizing, alcohol-induced acute pancreatitis, complicated by acute superior MVT.","The patient in this case was eventually transitioned to rivaroxaban and discharged on day 4. Since his discharge, he has entered into alcohol rehabilitation and remains compliant with his anticoagulation."],"date":"October 02, 2020","figures":[],"markdown":"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\n\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \n **Date:** October 02, 2020\n\n ## Content\n\n Treatment for MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal exams. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence. If evidence of clinical deterioration and bowel infarction is present, surgical intervention is necessary. Broad-spectrum antibiotics are generally reserved for the setting of pylephlebitis, septic thrombophlebitis, and sepsis secondary to bacterial translocation from an infarcted bowel.[2]\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed.[6]Research has shown that once a patient is transitioned to oral anticoagulation, treatment should continue for 3-6 months, unless a thrombophilia has been diagnosed. After anticoagulation, most MVTs partially or completely recanalize, with one study showing recanalization in 80% of patients who received anticoagulation.[7] However, the recurrence rate has been reported at 15%.\nAcute MVT carries a better prognosis than acute mesenteric ischemia. In one systematic review of nearly 3700 cases of acute mesenteric ischemia from 1966 to 2002, the mortality rate of those patients with MVT was 44%, compared with as much as 89% for those patients with advancement to mesenteric ischemia.[8] However, with increasing physician awareness, the use of contrast-enhanced CT to investigate abdominal pain in combination with anticoagulation has improved outcomes in these patients. In more modern studies, the mortality rate of acute MVT is down to 20%, with the most common cause of death being sepsis and multiorgan failure.[8]\nIn conclusion, acute superior MVT is a rare but important cause of mesenteric intestinal ischemia. It requires a high index of clinical suspicion. Rapid recognition and aggressive therapy are of extreme importance in order to prevent ischemic and infarcted bowel, sepsis, multiorgan failure, and eventual death. The 49-year-old man in this case had nonnecrotizing, alcohol-induced acute pancreatitis, complicated by acute superior MVT.\nThe patient in this case was eventually transitioned to rivaroxaban and discharged on day 4. Since his discharge, he has entered into alcohol rehabilitation and remains compliant with his anticoagulation.\n\n ## Figures\n\n \n*Page 5 of 6*","pagination":{"current_page":5,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281948,"choiceText":"Pancreatic and inflammatory bowel disease","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281950,"choiceText":"Portal hypertension","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281952,"choiceText":"Factor V Leiden mutation","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281954,"choiceText":"Splenectomy","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281956,"choiceText":"Gastric sleeve","correct":false,"displayOrder":5,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281958,"choiceText":"All of the above\r\n","correct":true,"displayOrder":6,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"MVT has many associated risk factors, including direct injury, venous congestive/stasis, and hypercoagulable conditions. The patient in this case had an extensive history of alcohol abuse and pancreatitis. In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408511,"questionText":"Which of the following is considered a risk factor for the development of MVT?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281960,"choiceText":"Broad-spectrum antibiotic use is contraindicated at this point","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281962,"choiceText":"Surgical consultation is unnecessary at this point","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281964,"choiceText":"Anticoagulation should be delayed until further investigation is done","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281966,"choiceText":"Bowel rest and fluid resuscitation should be promptly initiated","correct":true,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Treatment of MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal examinations. In this particular case, the patient is septic and has evidence of an intra-abdominal source in the setting of SMV thrombosis. If evidence suggests clinical deterioration and bowel infarction, surgical intervention is necessary.<br><br>\r\n\r\nIn this case, the patient has voluntary guarding and an elevated lactic acid level, making an emergent surgical consult necessary. Broad-spectrum antibiotics are generally reserved for patients with pylephlebitis, those with septic thrombophlebitis, and those with sepsis secondary to bacterial translocation from an infarcted bowel.\r\n<br><br>\r\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence.\r\n","displayOrder":3,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408513,"questionText":"A 53-year-old man with a significant medical history of pancreatitis presents to the ED with nausea, vomiting, and abdominal pain. His vital signs are notable for a heart rate of 113 beats/min, respiratory rate of 24 breaths/min, and a blood pressure of 96/50 mm Hg, with a temperature of 101.3°F (38.5°C). Abdominal examination reveals diffuse tenderness to palpation with voluntary guarding. Laboratory values are notable for a lactic acid level of 4.6 mmol/L, neutrophil-predominant leukocytosis of 19 × 10<sup>9</sup> cells/L, and a lipase level of 459 U/L. CT of the abdomen/pelvis reveals superior MVT. \r\n<br><br>\r\nWhich of the following is accurate regarding his treatment?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old"},{"authors":"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO","content":[],"date":"October 02, 2020","figures":[],"markdown":"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\n\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \n **Date:** October 02, 2020\n\n ## Content\n\n \n\n ## Figures\n\n \n*Page 6 of 6*","pagination":{"current_page":6,"total_pages":6},"questionnaire":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281948,"choiceText":"Pancreatic and inflammatory bowel disease","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281950,"choiceText":"Portal hypertension","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281952,"choiceText":"Factor V Leiden mutation","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281954,"choiceText":"Splenectomy","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281956,"choiceText":"Gastric sleeve","correct":false,"displayOrder":5,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281958,"choiceText":"All of the above\r\n","correct":true,"displayOrder":6,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"MVT has many associated risk factors, including direct injury, venous congestive/stasis, and hypercoagulable conditions. The patient in this case had an extensive history of alcohol abuse and pancreatitis. In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408511,"questionText":"Which of the following is considered a risk factor for the development of MVT?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281960,"choiceText":"Broad-spectrum antibiotic use is contraindicated at this point","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281962,"choiceText":"Surgical consultation is unnecessary at this point","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281964,"choiceText":"Anticoagulation should be delayed until further investigation is done","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281966,"choiceText":"Bowel rest and fluid resuscitation should be promptly initiated","correct":true,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Treatment of MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal examinations. In this particular case, the patient is septic and has evidence of an intra-abdominal source in the setting of SMV thrombosis. If evidence suggests clinical deterioration and bowel infarction, surgical intervention is necessary.<br><br>\r\n\r\nIn this case, the patient has voluntary guarding and an elevated lactic acid level, making an emergent surgical consult necessary. Broad-spectrum antibiotics are generally reserved for patients with pylephlebitis, those with septic thrombophlebitis, and those with sepsis secondary to bacterial translocation from an infarcted bowel.\r\n<br><br>\r\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence.\r\n","displayOrder":3,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408513,"questionText":"A 53-year-old man with a significant medical history of pancreatitis presents to the ED with nausea, vomiting, and abdominal pain. His vital signs are notable for a heart rate of 113 beats/min, respiratory rate of 24 breaths/min, and a blood pressure of 96/50 mm Hg, with a temperature of 101.3°F (38.5°C). Abdominal examination reveals diffuse tenderness to palpation with voluntary guarding. Laboratory values are notable for a lactic acid level of 4.6 mmol/L, neutrophil-predominant leukocytosis of 19 × 10<sup>9</sup> cells/L, and a lipase level of 459 U/L. CT of the abdomen/pelvis reveals superior MVT. \r\n<br><br>\r\nWhich of the following is accurate regarding his treatment?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"title":"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old"}],"string":"[\n {\n \"authors\": \"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO\",\n \"content\": [\n \"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.\",\n \"A 49-year-old man with a significant medical history of alcohol abuse, tobacco dependence, and pancreatitis presents to the emergency department (ED) with abdominal pain that has lasted for 3 days. The abdominal pain has been intermittent, achy, and located in the periumbilical region. Associated symptoms have included nausea and vomiting, with several episodes of watery, brown diarrhea.\",\n \"The patient reports a history of alcohol abuse, stating that he has ingested at least 1 pint a day since he was a teenager. He states that this pain feels different from the pain associated with his last bout of pancreatitis.\"\n ],\n \"date\": \"October 02, 2020\",\n \"figures\": [],\n \"markdown\": \"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\\n\\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \\n **Date:** October 02, 2020\\n\\n ## Content\\n\\n Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.\\nA 49-year-old man with a significant medical history of alcohol abuse, tobacco dependence, and pancreatitis presents to the emergency department (ED) with abdominal pain that has lasted for 3 days. The abdominal pain has been intermittent, achy, and located in the periumbilical region. Associated symptoms have included nausea and vomiting, with several episodes of watery, brown diarrhea.\\nThe patient reports a history of alcohol abuse, stating that he has ingested at least 1 pint a day since he was a teenager. He states that this pain feels different from the pain associated with his last bout of pancreatitis.\\n\\n ## Figures\\n\\n \\n*Page 1 of 6*\",\n \"pagination\": {\n \"current_page\": 1,\n \"total_pages\": 6\n },\n \"questionnaire\": [],\n \"title\": \"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\"\n },\n {\n \"authors\": \"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO\",\n \"content\": [\n \"Upon arrival to the ED, the patient has a temperature of 97.9°F (36.6°C), a heart rate of 91 beats/min, a respiratory rate of 23 breaths/min, blood pressure of 113/85 mm Hg, and 98% saturation on room air.\",\n \"Upon physical examination, he appears uncomfortable and is lying on his right side; he is slightly diaphoretic, with dry oral mucosa. Abdominal examination reveals a soft abdomen with apparent tenderness to palpation in the epigastric and periumbilical region, with minimal left upper-quadrant pain. His abdominal pain appears out of proportion to the physical examination findings.\",\n \"His laboratory values are as follows:\",\n \"White blood cell count: 13,000 cells/µL (reference range, 4,000-11,000 cells/µL)\",\n \"Hemoglobin level: 14.1 g/dL (reference range, 13.5-17.5 g/dL)\",\n \"Hematocrit: 39% (reference range, 41%-50%)\",\n \"Platelet count: 506,000 cells/µL (reference range, 150,000-400,000 cells/µL)\",\n \"Aspartate aminotransferase level: 126 U/L (reference range, 6-34 IU/L)\",\n \"Alanine aminotransferase level: 81 U/L (reference range, 7-55 U/L)\",\n \"Amylase level: 125 U/L (reference range, 30-110 U/L)\",\n \"Lipase level: 419 U/L (reference range, 0-160 U/L)\",\n \"Gamma glutamyltransferase level: 58 U/L (reference range, 8-38 U/L)\",\n \"Lactate dehydrogenase level: 175 U/L (reference range, 140-280 U/L)\",\n \"Lactic acid level: 0.7 mmol/L (reference range, 0.5-2.2 mmol/L)\",\n \"Glucose level: 102 mg/dL (reference range, <100 mg/dL)\",\n \"Rectal examination findings are negative for occult blood. All other laboratory values are unremarkable, including alcohol level. Subsequent CT of the abdomen/pelvis with intravenous contrast was performed (Figures 1-3).\",\n \"Figure 1.\",\n \"Figure 2.\",\n \"Figure 3.\"\n ],\n \"date\": \"October 02, 2020\",\n \"figures\": [\n {\n \"caption\": \"Figure 1.\",\n \"image_url\": \"https://img.medscapestatic.com/article/904/350/904350-Thumb1.png\"\n },\n {\n \"caption\": \"Figure 2.\",\n \"image_url\": \"https://img.medscapestatic.com/article/904/350/904350-Thumb2.png\"\n },\n {\n \"caption\": \"Figure 3.\",\n \"image_url\": \"https://img.medscapestatic.com/article/904/350/904350-Thumb3.png\"\n }\n ],\n \"markdown\": \"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\\n\\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \\n **Date:** October 02, 2020\\n\\n ## Content\\n\\n Upon arrival to the ED, the patient has a temperature of 97.9°F (36.6°C), a heart rate of 91 beats/min, a respiratory rate of 23 breaths/min, blood pressure of 113/85 mm Hg, and 98% saturation on room air.\\nUpon physical examination, he appears uncomfortable and is lying on his right side; he is slightly diaphoretic, with dry oral mucosa. Abdominal examination reveals a soft abdomen with apparent tenderness to palpation in the epigastric and periumbilical region, with minimal left upper-quadrant pain. His abdominal pain appears out of proportion to the physical examination findings.\\nHis laboratory values are as follows:\\nWhite blood cell count: 13,000 cells/µL (reference range, 4,000-11,000 cells/µL)\\nHemoglobin level: 14.1 g/dL (reference range, 13.5-17.5 g/dL)\\nHematocrit: 39% (reference range, 41%-50%)\\nPlatelet count: 506,000 cells/µL (reference range, 150,000-400,000 cells/µL)\\nAspartate aminotransferase level: 126 U/L (reference range, 6-34 IU/L)\\nAlanine aminotransferase level: 81 U/L (reference range, 7-55 U/L)\\nAmylase level: 125 U/L (reference range, 30-110 U/L)\\nLipase level: 419 U/L (reference range, 0-160 U/L)\\nGamma glutamyltransferase level: 58 U/L (reference range, 8-38 U/L)\\nLactate dehydrogenase level: 175 U/L (reference range, 140-280 U/L)\\nLactic acid level: 0.7 mmol/L (reference range, 0.5-2.2 mmol/L)\\nGlucose level: 102 mg/dL (reference range, <100 mg/dL)\\nRectal examination findings are negative for occult blood. All other laboratory values are unremarkable, including alcohol level. Subsequent CT of the abdomen/pelvis with intravenous contrast was performed (Figures 1-3).\\nFigure 1.\\nFigure 2.\\nFigure 3.\\n\\n ## Figures\\n\\n **Figure 1.** \\n \\n\\n**Figure 2.** \\n \\n\\n**Figure 3.** \\n \\n\\n\\n*Page 2 of 6*\",\n \"pagination\": {\n \"current_page\": 2,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281940,\n \"choiceText\": \"Splenic vein thrombosis\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281942,\n \"choiceText\": \"Superior mesenteric vein thrombosis\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281944,\n \"choiceText\": \"Mesenteric arterial thrombosis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281946,\n \"choiceText\": \"Septic pylephlebitis\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408509,\n \"questionText\": \"Based only on these findings, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\"\n },\n {\n \"authors\": \"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO\",\n \"content\": [\n \"Acute mesenteric vein thrombosis (MVT) is a rare but extremely important cause of mesenteric intestinal ischemia. In this patient, CT of the abdomen/pelvis with intravenous contrast revealed a filling defect that was consistent with acute thrombosis within the superior mesenteric vein (SMV), which extends approximately 3 cm cephalad to the portosplenic confluence. Other associated findings on these images included peripancreatic fat stranding and peripancreatic fluid consistent with acute pancreatitis (Figures 1-3).\",\n \"Figure 1.\",\n \"Figure 2.\",\n \"Figure 3.\",\n \"Pancreatitis results in a vast spectrum of both arterial and venous complications. The vascular complications involved in pancreatitis are major causes of morbidity and mortality. The venous complications result from thrombosis of the splenic vein and, less commonly, the portal vein and the SMV, as seen in the patient in this case. Prompt recognition is of paramount importance and requires a high index of clinical suspicion because aggressive therapy and anticoagulation can limit progression of the potential devastating consequences.\",\n \"Patients with acute pancreatitis can present with portal vein thrombosis, splenic vein thrombosis, or (less commonly) superior MVT. Clinical research has shown that an isolated venous thrombosis to only the SMV, without simultaneous involvement of either the portal vein or the splenic vein, is rare. This vascular complication is important because of the increased risk for mesenteric ischemia and bowel infarction if not recognized.[1]\",\n \"MVT is considered a rare condition, with only 1 case per 5000-15000 inpatient admissions per year; it accounts for roughly 6%-9% of all cases of acute mesenteric ischemia.[2] In a systematic review of 3692 patients from 1966 to 2002, MVT was the cause of acute mesenteric ischemia in about 3% of patients.[3]\"\n ],\n \"date\": \"October 02, 2020\",\n \"figures\": [\n {\n \"caption\": \"Figure 1.\",\n \"image_url\": \"https://img.medscapestatic.com/article/904/350/904350-Thumb1.png\"\n },\n {\n \"caption\": \"Figure 2.\",\n \"image_url\": \"https://img.medscapestatic.com/article/904/350/904350-Thumb2.png\"\n },\n {\n \"caption\": \"Figure 3.\",\n \"image_url\": \"https://img.medscapestatic.com/article/904/350/904350-Thumb3.png\"\n }\n ],\n \"markdown\": \"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\\n\\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \\n **Date:** October 02, 2020\\n\\n ## Content\\n\\n Acute mesenteric vein thrombosis (MVT) is a rare but extremely important cause of mesenteric intestinal ischemia. In this patient, CT of the abdomen/pelvis with intravenous contrast revealed a filling defect that was consistent with acute thrombosis within the superior mesenteric vein (SMV), which extends approximately 3 cm cephalad to the portosplenic confluence. Other associated findings on these images included peripancreatic fat stranding and peripancreatic fluid consistent with acute pancreatitis (Figures 1-3).\\nFigure 1.\\nFigure 2.\\nFigure 3.\\nPancreatitis results in a vast spectrum of both arterial and venous complications. The vascular complications involved in pancreatitis are major causes of morbidity and mortality. The venous complications result from thrombosis of the splenic vein and, less commonly, the portal vein and the SMV, as seen in the patient in this case. Prompt recognition is of paramount importance and requires a high index of clinical suspicion because aggressive therapy and anticoagulation can limit progression of the potential devastating consequences.\\nPatients with acute pancreatitis can present with portal vein thrombosis, splenic vein thrombosis, or (less commonly) superior MVT. Clinical research has shown that an isolated venous thrombosis to only the SMV, without simultaneous involvement of either the portal vein or the splenic vein, is rare. This vascular complication is important because of the increased risk for mesenteric ischemia and bowel infarction if not recognized.[1]\\nMVT is considered a rare condition, with only 1 case per 5000-15000 inpatient admissions per year; it accounts for roughly 6%-9% of all cases of acute mesenteric ischemia.[2] In a systematic review of 3692 patients from 1966 to 2002, MVT was the cause of acute mesenteric ischemia in about 3% of patients.[3]\\n\\n ## Figures\\n\\n **Figure 1.** \\n \\n\\n**Figure 2.** \\n \\n\\n**Figure 3.** \\n \\n\\n\\n*Page 3 of 6*\",\n \"pagination\": {\n \"current_page\": 3,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281940,\n \"choiceText\": \"Splenic vein thrombosis\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281942,\n \"choiceText\": \"Superior mesenteric vein thrombosis\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281944,\n \"choiceText\": \"Mesenteric arterial thrombosis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281946,\n \"choiceText\": \"Septic pylephlebitis\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408509,\n \"questionText\": \"Based only on these findings, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\"\n },\n {\n \"authors\": \"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO\",\n \"content\": [\n \"Many risk factors for MVT are recognized, including direct injury (eg, abdominal trauma, splenectomy, intra-abdominal inflammatory processes), venous congestion/stasis (eg, congestive heart failure, portal hypertension, cirrhosis), and hypercoagulable conditions (eg, protein C/S deficiency, antithrombin III deficiency, factor V Leiden mutation, pancreatic/colon carcinoma, oral contraceptive use, polycythemia vera, heparin-induced thrombocytopenia, lupus anticoagulant/anti-phospholipid syndrome).[4] In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.[5]\",\n \"Acute occlusion of the mesenteric vein results in increased resistance within the mesenteric venous bed, leading to decreased perfusion pressure.[3] As flow stagnates in the mesenteric vein, increased venous pressure results in an efflux of fluid into the tissues, leading to bowel-wall edema. If the clinical progression continues, venous return from the bowel wall is completely occluded, and the end result is bowel ischemia.[3] Integrity of the bowel mucosa is lost and bacteria can translocate, leading to lactic acidosis, sepsis, multiorgan failure, and eventually death.[2]\",\n \"MVT can occur acutely, subacutely, or chronically. The clinical features vary, depending on the location of the thrombus within the splanchnic vasculature.[3] Acute MVT, similar to other forms of acute mesenteric ischemia, presents most often as a colicky periumbilical pain that is often out of proportion to the physical examination findings. However, the onset of venous thrombosis, compared with arterial thrombosis, is often less sudden and dull, with as many as 75% of patients presenting after 2 days of abdominal pain.[3]\",\n \"Alternatively, chronic mesenteric venous thrombosis often presents with portal hypertension and variceal hemorrhage.[2] In general, peritoneal signs are absent, unless the venous thrombosis goes untreated and the bowel becomes ischemic, in which case peritoneal signs develop.\",\n \"In a retrospective study, 31 patients diagnosed with MVT from 1985-1999 were reviewed.[4] Approximately 84% of patients presented with abdominal pain, with 16% presenting with peritoneal signs. Common overall symptoms included diarrhea (42%), nausea and vomiting (32%), lower gastrointestinal bleeding (19%), fatigue (16%), and upper gastrointestinal bleeding (10%). Furthermore, only 22 patients were initially treated with heparin. Five patients were found to have peritonitis and underwent exploratory laparotomy, with the ultimate goal to prevent or limit gangrenous bowel, with an additional five patients later undergoing surgery for the development of ischemic bowel. Seven of the 31 patients died within 30 days, secondary to complications from infarcted bowel and multisystemic organ failure. Overall, 19 of the 24 survivors were treated with long-term anticoagulation, with 88% of those surviving long-term.\",\n \"Differentiating between ischemia secondary to MVT and ischemia secondary to a mesenteric arterial thrombosis is important. MVT presents in the setting of thrombophilia or an inflammatory abdominal process, whereas mesenteric arterial ischemia presents in the setting of cardiac disease, low-flow states, and atrial fibrillation.[1] Similar to all forms of mesenteric ischemia, no clinical features are specific to MVT. As such, a clinician must have a high index of suspicion in order to make an early diagnosis and avoid the complications of an undiagnosed MVT.\"\n ],\n \"date\": \"October 02, 2020\",\n \"figures\": [],\n \"markdown\": \"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\\n\\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \\n **Date:** October 02, 2020\\n\\n ## Content\\n\\n Many risk factors for MVT are recognized, including direct injury (eg, abdominal trauma, splenectomy, intra-abdominal inflammatory processes), venous congestion/stasis (eg, congestive heart failure, portal hypertension, cirrhosis), and hypercoagulable conditions (eg, protein C/S deficiency, antithrombin III deficiency, factor V Leiden mutation, pancreatic/colon carcinoma, oral contraceptive use, polycythemia vera, heparin-induced thrombocytopenia, lupus anticoagulant/anti-phospholipid syndrome).[4] In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.[5]\\nAcute occlusion of the mesenteric vein results in increased resistance within the mesenteric venous bed, leading to decreased perfusion pressure.[3] As flow stagnates in the mesenteric vein, increased venous pressure results in an efflux of fluid into the tissues, leading to bowel-wall edema. If the clinical progression continues, venous return from the bowel wall is completely occluded, and the end result is bowel ischemia.[3] Integrity of the bowel mucosa is lost and bacteria can translocate, leading to lactic acidosis, sepsis, multiorgan failure, and eventually death.[2]\\nMVT can occur acutely, subacutely, or chronically. The clinical features vary, depending on the location of the thrombus within the splanchnic vasculature.[3] Acute MVT, similar to other forms of acute mesenteric ischemia, presents most often as a colicky periumbilical pain that is often out of proportion to the physical examination findings. However, the onset of venous thrombosis, compared with arterial thrombosis, is often less sudden and dull, with as many as 75% of patients presenting after 2 days of abdominal pain.[3]\\nAlternatively, chronic mesenteric venous thrombosis often presents with portal hypertension and variceal hemorrhage.[2] In general, peritoneal signs are absent, unless the venous thrombosis goes untreated and the bowel becomes ischemic, in which case peritoneal signs develop.\\nIn a retrospective study, 31 patients diagnosed with MVT from 1985-1999 were reviewed.[4] Approximately 84% of patients presented with abdominal pain, with 16% presenting with peritoneal signs. Common overall symptoms included diarrhea (42%), nausea and vomiting (32%), lower gastrointestinal bleeding (19%), fatigue (16%), and upper gastrointestinal bleeding (10%). Furthermore, only 22 patients were initially treated with heparin. Five patients were found to have peritonitis and underwent exploratory laparotomy, with the ultimate goal to prevent or limit gangrenous bowel, with an additional five patients later undergoing surgery for the development of ischemic bowel. Seven of the 31 patients died within 30 days, secondary to complications from infarcted bowel and multisystemic organ failure. Overall, 19 of the 24 survivors were treated with long-term anticoagulation, with 88% of those surviving long-term.\\nDifferentiating between ischemia secondary to MVT and ischemia secondary to a mesenteric arterial thrombosis is important. MVT presents in the setting of thrombophilia or an inflammatory abdominal process, whereas mesenteric arterial ischemia presents in the setting of cardiac disease, low-flow states, and atrial fibrillation.[1] Similar to all forms of mesenteric ischemia, no clinical features are specific to MVT. As such, a clinician must have a high index of suspicion in order to make an early diagnosis and avoid the complications of an undiagnosed MVT.\\n\\n ## Figures\\n\\n \\n*Page 4 of 6*\",\n \"pagination\": {\n \"current_page\": 4,\n \"total_pages\": 6\n },\n \"questionnaire\": [],\n \"title\": \"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\"\n },\n {\n \"authors\": \"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO\",\n \"content\": [\n \"Treatment for MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal exams. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence. If evidence of clinical deterioration and bowel infarction is present, surgical intervention is necessary. Broad-spectrum antibiotics are generally reserved for the setting of pylephlebitis, septic thrombophlebitis, and sepsis secondary to bacterial translocation from an infarcted bowel.[2]\",\n \"Initiation of anticoagulation remains the cornerstone of treatment and should not be delayed.[6]Research has shown that once a patient is transitioned to oral anticoagulation, treatment should continue for 3-6 months, unless a thrombophilia has been diagnosed. After anticoagulation, most MVTs partially or completely recanalize, with one study showing recanalization in 80% of patients who received anticoagulation.[7] However, the recurrence rate has been reported at 15%.\",\n \"Acute MVT carries a better prognosis than acute mesenteric ischemia. In one systematic review of nearly 3700 cases of acute mesenteric ischemia from 1966 to 2002, the mortality rate of those patients with MVT was 44%, compared with as much as 89% for those patients with advancement to mesenteric ischemia.[8] However, with increasing physician awareness, the use of contrast-enhanced CT to investigate abdominal pain in combination with anticoagulation has improved outcomes in these patients. In more modern studies, the mortality rate of acute MVT is down to 20%, with the most common cause of death being sepsis and multiorgan failure.[8]\",\n \"In conclusion, acute superior MVT is a rare but important cause of mesenteric intestinal ischemia. It requires a high index of clinical suspicion. Rapid recognition and aggressive therapy are of extreme importance in order to prevent ischemic and infarcted bowel, sepsis, multiorgan failure, and eventual death. The 49-year-old man in this case had nonnecrotizing, alcohol-induced acute pancreatitis, complicated by acute superior MVT.\",\n \"The patient in this case was eventually transitioned to rivaroxaban and discharged on day 4. Since his discharge, he has entered into alcohol rehabilitation and remains compliant with his anticoagulation.\"\n ],\n \"date\": \"October 02, 2020\",\n \"figures\": [],\n \"markdown\": \"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\\n\\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \\n **Date:** October 02, 2020\\n\\n ## Content\\n\\n Treatment for MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal exams. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence. If evidence of clinical deterioration and bowel infarction is present, surgical intervention is necessary. Broad-spectrum antibiotics are generally reserved for the setting of pylephlebitis, septic thrombophlebitis, and sepsis secondary to bacterial translocation from an infarcted bowel.[2]\\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed.[6]Research has shown that once a patient is transitioned to oral anticoagulation, treatment should continue for 3-6 months, unless a thrombophilia has been diagnosed. After anticoagulation, most MVTs partially or completely recanalize, with one study showing recanalization in 80% of patients who received anticoagulation.[7] However, the recurrence rate has been reported at 15%.\\nAcute MVT carries a better prognosis than acute mesenteric ischemia. In one systematic review of nearly 3700 cases of acute mesenteric ischemia from 1966 to 2002, the mortality rate of those patients with MVT was 44%, compared with as much as 89% for those patients with advancement to mesenteric ischemia.[8] However, with increasing physician awareness, the use of contrast-enhanced CT to investigate abdominal pain in combination with anticoagulation has improved outcomes in these patients. In more modern studies, the mortality rate of acute MVT is down to 20%, with the most common cause of death being sepsis and multiorgan failure.[8]\\nIn conclusion, acute superior MVT is a rare but important cause of mesenteric intestinal ischemia. It requires a high index of clinical suspicion. Rapid recognition and aggressive therapy are of extreme importance in order to prevent ischemic and infarcted bowel, sepsis, multiorgan failure, and eventual death. The 49-year-old man in this case had nonnecrotizing, alcohol-induced acute pancreatitis, complicated by acute superior MVT.\\nThe patient in this case was eventually transitioned to rivaroxaban and discharged on day 4. Since his discharge, he has entered into alcohol rehabilitation and remains compliant with his anticoagulation.\\n\\n ## Figures\\n\\n \\n*Page 5 of 6*\",\n \"pagination\": {\n \"current_page\": 5,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281948,\n \"choiceText\": \"Pancreatic and inflammatory bowel disease\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281950,\n \"choiceText\": \"Portal hypertension\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281952,\n \"choiceText\": \"Factor V Leiden mutation\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281954,\n \"choiceText\": \"Splenectomy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281956,\n \"choiceText\": \"Gastric sleeve\",\n \"correct\": false,\n \"displayOrder\": 5,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281958,\n \"choiceText\": \"All of the above\\r\\n\",\n \"correct\": true,\n \"displayOrder\": 6,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"MVT has many associated risk factors, including direct injury, venous congestive/stasis, and hypercoagulable conditions. The patient in this case had an extensive history of alcohol abuse and pancreatitis. In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408511,\n \"questionText\": \"Which of the following is considered a risk factor for the development of MVT?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281960,\n \"choiceText\": \"Broad-spectrum antibiotic use is contraindicated at this point\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281962,\n \"choiceText\": \"Surgical consultation is unnecessary at this point\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281964,\n \"choiceText\": \"Anticoagulation should be delayed until further investigation is done\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281966,\n \"choiceText\": \"Bowel rest and fluid resuscitation should be promptly initiated\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Treatment of MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal examinations. In this particular case, the patient is septic and has evidence of an intra-abdominal source in the setting of SMV thrombosis. If evidence suggests clinical deterioration and bowel infarction, surgical intervention is necessary.<br><br>\\r\\n\\r\\nIn this case, the patient has voluntary guarding and an elevated lactic acid level, making an emergent surgical consult necessary. Broad-spectrum antibiotics are generally reserved for patients with pylephlebitis, those with septic thrombophlebitis, and those with sepsis secondary to bacterial translocation from an infarcted bowel.\\r\\n<br><br>\\r\\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence.\\r\\n\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408513,\n \"questionText\": \"A 53-year-old man with a significant medical history of pancreatitis presents to the ED with nausea, vomiting, and abdominal pain. His vital signs are notable for a heart rate of 113 beats/min, respiratory rate of 24 breaths/min, and a blood pressure of 96/50 mm Hg, with a temperature of 101.3°F (38.5°C). Abdominal examination reveals diffuse tenderness to palpation with voluntary guarding. Laboratory values are notable for a lactic acid level of 4.6 mmol/L, neutrophil-predominant leukocytosis of 19 × 10<sup>9</sup> cells/L, and a lipase level of 459 U/L. CT of the abdomen/pelvis reveals superior MVT. \\r\\n<br><br>\\r\\nWhich of the following is accurate regarding his treatment?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\"\n },\n {\n \"authors\": \"Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO\",\n \"content\": [],\n \"date\": \"October 02, 2020\",\n \"figures\": [],\n \"markdown\": \"# Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\\n\\n **Authors:** Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO \\n **Date:** October 02, 2020\\n\\n ## Content\\n\\n \\n\\n ## Figures\\n\\n \\n*Page 6 of 6*\",\n \"pagination\": {\n \"current_page\": 6,\n \"total_pages\": 6\n },\n \"questionnaire\": [\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281948,\n \"choiceText\": \"Pancreatic and inflammatory bowel disease\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281950,\n \"choiceText\": \"Portal hypertension\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281952,\n \"choiceText\": \"Factor V Leiden mutation\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281954,\n \"choiceText\": \"Splenectomy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281956,\n \"choiceText\": \"Gastric sleeve\",\n \"correct\": false,\n \"displayOrder\": 5,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281958,\n \"choiceText\": \"All of the above\\r\\n\",\n \"correct\": true,\n \"displayOrder\": 6,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"MVT has many associated risk factors, including direct injury, venous congestive/stasis, and hypercoagulable conditions. The patient in this case had an extensive history of alcohol abuse and pancreatitis. In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408511,\n \"questionText\": \"Which of the following is considered a risk factor for the development of MVT?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281960,\n \"choiceText\": \"Broad-spectrum antibiotic use is contraindicated at this point\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281962,\n \"choiceText\": \"Surgical consultation is unnecessary at this point\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281964,\n \"choiceText\": \"Anticoagulation should be delayed until further investigation is done\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281966,\n \"choiceText\": \"Bowel rest and fluid resuscitation should be promptly initiated\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Treatment of MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal examinations. In this particular case, the patient is septic and has evidence of an intra-abdominal source in the setting of SMV thrombosis. If evidence suggests clinical deterioration and bowel infarction, surgical intervention is necessary.<br><br>\\r\\n\\r\\nIn this case, the patient has voluntary guarding and an elevated lactic acid level, making an emergent surgical consult necessary. Broad-spectrum antibiotics are generally reserved for patients with pylephlebitis, those with septic thrombophlebitis, and those with sepsis secondary to bacterial translocation from an infarcted bowel.\\r\\n<br><br>\\r\\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence.\\r\\n\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408513,\n \"questionText\": \"A 53-year-old man with a significant medical history of pancreatitis presents to the ED with nausea, vomiting, and abdominal pain. His vital signs are notable for a heart rate of 113 beats/min, respiratory rate of 24 breaths/min, and a blood pressure of 96/50 mm Hg, with a temperature of 101.3°F (38.5°C). Abdominal examination reveals diffuse tenderness to palpation with voluntary guarding. Laboratory values are notable for a lactic acid level of 4.6 mmol/L, neutrophil-predominant leukocytosis of 19 × 10<sup>9</sup> cells/L, and a lipase level of 459 U/L. CT of the abdomen/pelvis reveals superior MVT. \\r\\n<br><br>\\r\\nWhich of the following is accurate regarding his treatment?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n ],\n \"title\": \"Alcohol Abuse and Unusual Abdominal Pain in a 49-Year-Old\"\n }\n]","isConversational":false},"questions":{"kind":"list like","value":[{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281940,"choiceText":"Splenic vein thrombosis","correct":false,"displayOrder":1,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281942,"choiceText":"Superior mesenteric vein thrombosis","correct":true,"displayOrder":2,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281944,"choiceText":"Mesenteric arterial thrombosis","correct":false,"displayOrder":3,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281946,"choiceText":"Septic pylephlebitis\r\n","correct":false,"displayOrder":4,"explanation":"","hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"","displayOrder":1,"displayType":1,"horizontal":false,"introduction":"","matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408509,"questionText":"Based only on these findings, which of the following is the most likely diagnosis?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281948,"choiceText":"Pancreatic and inflammatory bowel disease","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281950,"choiceText":"Portal hypertension","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281952,"choiceText":"Factor V Leiden mutation","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281954,"choiceText":"Splenectomy","correct":false,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281956,"choiceText":"Gastric sleeve","correct":false,"displayOrder":5,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281958,"choiceText":"All of the above\r\n","correct":true,"displayOrder":6,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"MVT has many associated risk factors, including direct injury, venous congestive/stasis, and hypercoagulable conditions. The patient in this case had an extensive history of alcohol abuse and pancreatitis. In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.","displayOrder":2,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408511,"questionText":"Which of the following is considered a risk factor for the development of MVT?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false},{"answered":false,"answeredCorrectly":false,"branch":false,"choices":[{"branchPath":null,"choiceId":1281960,"choiceText":"Broad-spectrum antibiotic use is contraindicated at this point","correct":false,"displayOrder":1,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281962,"choiceText":"Surgical consultation is unnecessary at this point","correct":false,"displayOrder":2,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281964,"choiceText":"Anticoagulation should be delayed until further investigation is done","correct":false,"displayOrder":3,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"},{"branchPath":null,"choiceId":1281966,"choiceText":"Bowel rest and fluid resuscitation should be promptly initiated","correct":true,"displayOrder":4,"explanation":null,"hideLabel":false,"selected":false,"totalAbsoluteResponseCount":0,"totalResponses":"0"}],"discussion":"Treatment of MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal examinations. In this particular case, the patient is septic and has evidence of an intra-abdominal source in the setting of SMV thrombosis. If evidence suggests clinical deterioration and bowel infarction, surgical intervention is necessary.<br><br>\r\n\r\nIn this case, the patient has voluntary guarding and an elevated lactic acid level, making an emergent surgical consult necessary. Broad-spectrum antibiotics are generally reserved for patients with pylephlebitis, those with septic thrombophlebitis, and those with sepsis secondary to bacterial translocation from an infarcted bowel.\r\n<br><br>\r\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence.\r\n","displayOrder":3,"displayType":1,"horizontal":false,"introduction":null,"matrixQuestions":[],"mutuallyExclusive":false,"poll":true,"professions":[],"questionId":408513,"questionText":"A 53-year-old man with a significant medical history of pancreatitis presents to the ED with nausea, vomiting, and abdominal pain. His vital signs are notable for a heart rate of 113 beats/min, respiratory rate of 24 breaths/min, and a blood pressure of 96/50 mm Hg, with a temperature of 101.3°F (38.5°C). Abdominal examination reveals diffuse tenderness to palpation with voluntary guarding. Laboratory values are notable for a lactic acid level of 4.6 mmol/L, neutrophil-predominant leukocytosis of 19 × 10<sup>9</sup> cells/L, and a lipase level of 459 U/L. CT of the abdomen/pelvis reveals superior MVT. \r\n<br><br>\r\nWhich of the following is accurate regarding his treatment?","questionTypeId":1,"required":false,"responseText":null,"score":false,"showAnsTable":true,"showQuestion":true,"showResult":true,"specialties":[],"totalResponses":0,"viewResults":false}],"string":"[\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281940,\n \"choiceText\": \"Splenic vein thrombosis\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281942,\n \"choiceText\": \"Superior mesenteric vein thrombosis\",\n \"correct\": true,\n \"displayOrder\": 2,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281944,\n \"choiceText\": \"Mesenteric arterial thrombosis\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281946,\n \"choiceText\": \"Septic pylephlebitis\\r\\n\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": \"\",\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"\",\n \"displayOrder\": 1,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": \"\",\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408509,\n \"questionText\": \"Based only on these findings, which of the following is the most likely diagnosis?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281948,\n \"choiceText\": \"Pancreatic and inflammatory bowel disease\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281950,\n \"choiceText\": \"Portal hypertension\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281952,\n \"choiceText\": \"Factor V Leiden mutation\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281954,\n \"choiceText\": \"Splenectomy\",\n \"correct\": false,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281956,\n \"choiceText\": \"Gastric sleeve\",\n \"correct\": false,\n \"displayOrder\": 5,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281958,\n \"choiceText\": \"All of the above\\r\\n\",\n \"correct\": true,\n \"displayOrder\": 6,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"MVT has many associated risk factors, including direct injury, venous congestive/stasis, and hypercoagulable conditions. The patient in this case had an extensive history of alcohol abuse and pancreatitis. In pancreatitis, the pathogenesis involves local venous congestion/stasis and spasm, with mass effect from the inflamed pancreas and damage to the wall of the veins by pancreatic enzymes.\",\n \"displayOrder\": 2,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408511,\n \"questionText\": \"Which of the following is considered a risk factor for the development of MVT?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n },\n {\n \"answered\": false,\n \"answeredCorrectly\": false,\n \"branch\": false,\n \"choices\": [\n {\n \"branchPath\": null,\n \"choiceId\": 1281960,\n \"choiceText\": \"Broad-spectrum antibiotic use is contraindicated at this point\",\n \"correct\": false,\n \"displayOrder\": 1,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281962,\n \"choiceText\": \"Surgical consultation is unnecessary at this point\",\n \"correct\": false,\n \"displayOrder\": 2,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281964,\n \"choiceText\": \"Anticoagulation should be delayed until further investigation is done\",\n \"correct\": false,\n \"displayOrder\": 3,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n },\n {\n \"branchPath\": null,\n \"choiceId\": 1281966,\n \"choiceText\": \"Bowel rest and fluid resuscitation should be promptly initiated\",\n \"correct\": true,\n \"displayOrder\": 4,\n \"explanation\": null,\n \"hideLabel\": false,\n \"selected\": false,\n \"totalAbsoluteResponseCount\": 0,\n \"totalResponses\": \"0\"\n }\n ],\n \"discussion\": \"Treatment of MVT is mainly conservative, involving systemic anticoagulation, bowel rest, fluid resuscitation, and serial abdominal examinations. In this particular case, the patient is septic and has evidence of an intra-abdominal source in the setting of SMV thrombosis. If evidence suggests clinical deterioration and bowel infarction, surgical intervention is necessary.<br><br>\\r\\n\\r\\nIn this case, the patient has voluntary guarding and an elevated lactic acid level, making an emergent surgical consult necessary. Broad-spectrum antibiotics are generally reserved for patients with pylephlebitis, those with septic thrombophlebitis, and those with sepsis secondary to bacterial translocation from an infarcted bowel.\\r\\n<br><br>\\r\\nInitiation of anticoagulation remains the cornerstone of treatment and should not be delayed. The ultimate goal is to prevent extension of the thrombus, avoid intestinal infarction, and prevent recurrence.\\r\\n\",\n \"displayOrder\": 3,\n \"displayType\": 1,\n \"horizontal\": false,\n \"introduction\": null,\n \"matrixQuestions\": [],\n \"mutuallyExclusive\": false,\n \"poll\": true,\n \"professions\": [],\n \"questionId\": 408513,\n \"questionText\": \"A 53-year-old man with a significant medical history of pancreatitis presents to the ED with nausea, vomiting, and abdominal pain. His vital signs are notable for a heart rate of 113 beats/min, respiratory rate of 24 breaths/min, and a blood pressure of 96/50 mm Hg, with a temperature of 101.3°F (38.5°C). Abdominal examination reveals diffuse tenderness to palpation with voluntary guarding. Laboratory values are notable for a lactic acid level of 4.6 mmol/L, neutrophil-predominant leukocytosis of 19 × 10<sup>9</sup> cells/L, and a lipase level of 459 U/L. CT of the abdomen/pelvis reveals superior MVT. \\r\\n<br><br>\\r\\nWhich of the following is accurate regarding his treatment?\",\n \"questionTypeId\": 1,\n \"required\": false,\n \"responseText\": null,\n \"score\": false,\n \"showAnsTable\": true,\n \"showQuestion\": true,\n \"showResult\": true,\n \"specialties\": [],\n \"totalResponses\": 0,\n \"viewResults\": false\n }\n]","isConversational":false}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":2,"numItemsPerPage":100,"numTotalItems":508,"offset":200,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTc3NDEzMzg5MCwic3ViIjoiL2RhdGFzZXRzL2hsbGovbWVkc2NhcGUiLCJleHAiOjE3NzQxMzc0OTAsImlzcyI6Imh0dHBzOi8vaHVnZ2luZ2ZhY2UuY28ifQ.YD_3-HUJhtw2iCn017KZqJ4NDqIPTsvrCWGShSTa474fkU7wE2gAL9Ok4n8ZHp6mY69cCF488k5Hu3FKJhLJBw","displayUrls":true,"splitSizeSummaries":[{"config":"default","split":"train","numRows":508,"numBytesParquet":8083831}]},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false,"savedQueries":{"community":[],"user":[]}}">
article_id stringlengths 6 7 | url stringlengths 19 20 | article_data listlengths 1 7 | questions listlengths 0 5 |
|---|---|---|---|
743272 | /viewarticle/743272 | [
{
"authors": "Linda A. Dultz, MD, MPH; Karina L. Vivar; Suzanne MacFarland; MaryAnn Hopkins, MD, MPhil",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to re... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 407467,
"choiceText": "Desmoid tumor\r\n",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
877716 | /viewarticle/877716 | [
{
"authors": "Shah Azmoon, MD; Matthew Budoff, MD; David Atkinson, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your di... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1082812,
"choiceText": "Pulmonary vein anomaly",
"correct": false,
"displayOrder": 1,
"explanation": null,
"hideLabel": false... |
984951 | /viewarticle/984951 | [
{
"authors": "Jonathan Katz, MD; Shivani Garg, MD, MS",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and trea... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1751269,
"choiceText": "Lupus nephritis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
984950 | /viewarticle/984950 | [
{
"authors": "Heidi Moawad, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1751149,
"choiceText": "Multiple sclerosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
724047 | /viewarticle/724047 | [
{
"authors": "Jansen Tiongson, MD; Lisa Chan, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 349495,
"choiceText": "Hypertrophic cardiomyopathy",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
729899 | /viewarticle/729899 | [
{
"authors": "Abraham A. Ayantunde, MB BS, FRCS; George G. Araklitis, MB BS, BSc",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. T... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 369595,
"choiceText": "External monitoring device",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fals... |
984871 | /viewarticle/984871 | [
{
"authors": "Vivian Vega, MD; Antonia Fernandez, MD; Simon S. Rabinowitz, MD, PhD; Meredith E. Pittman, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1747031,
"choiceText": "Hepatitis B virus infection",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fa... |
882400 | /viewarticle/882400 | [
{
"authors": "Noah Gudel, DO; Lisa M. Rock, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1116010,
"choiceText": "Primary epiploic appendagitis",
"correct": true,
"displayOrder": 1,
"explanation": "",
"hideLabel": f... |
888178 | /viewarticle/888178 | [
{
"authors": "Janice Verham, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using th... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1154934,
"choiceText": "Dissecting aortic aneurysm",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
913911 | /viewarticle/913911 | [
{
"authors": "Sumaira Nabi, MBBS; Shahzad Ahmed, MBBS; Mazhar Badshah, MBBS",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test y... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1365792,
"choiceText": "Tuberous sclerosis",
"correct": true,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
983918 | /viewarticle/983918 | [
{
"authors": "Malgorzata K. Nowakowska, BS; Saira George, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic a... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1739571,
"choiceText": "Cutaneous sarcoidosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
885566 | /viewarticle/885566 | [
{
"authors": "Vimon Seriburi, MD; Ann F. Fisher, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatm... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1136578,
"choiceText": "Diverticulitis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
983148 | /viewarticle/983148 | [
{
"authors": "Kristine M. Lohr, MD, MS; Muhammad Sohail Khan, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnost... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1737896,
"choiceText": "Reactive arthritis ",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
882771 | /viewarticle/882771 | [
{
"authors": "Nail Alouch, MD; Doina Ivan, MD; Phyu P. Aung, MD, PhD; Victor G. Prieto, MD, PhD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accuratel... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1117520,
"choiceText": "Melanoma in situ",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
889517 | /viewarticle/889517 | [
{
"authors": "Faizah Siddique, MD; Herbert S. Diamond, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1163814,
"choiceText": "Intravascular hemolysis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,... |
871259 | /viewarticle/871259 | [
{
"authors": "Tiffany Kwok, BHSc; Benjamin Barankin, MD, FRCPC",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnosti... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1031076,
"choiceText": "Acute generalized exanthematous pustulosis",
"correct": true,
"displayOrder": 1,
"explanation": "",
"... |
847975 | /viewarticle/847975 | [
{
"authors": "Carla R. Sterling, MD; Niccole Bart, MD",
"content": [
"Editor's Note:\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic an... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 869711,
"choiceText": "COPD exacerbation",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
981716 | /viewarticle/981716 | [
{
"authors": "Poornima Oruganti, MD, MPH; Jason Schairer, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic a... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1727327,
"choiceText": "Healing injury from mechanical fall",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLa... |
892848 | /viewarticle/892848 | [
{
"authors": "Dora Izaguirre-Anariba, MD, MPH, CHES; Hung-I Liao, MD; Jesus C. Lanza, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately reco... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1190168,
"choiceText": "AAT deficiency (AATD)",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
888807 | /viewarticle/888807 | [
{
"authors": "Niranjan N. Singh, MBBS, MD, DM",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment s... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1158164,
"choiceText": "Neuroacanthocytosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
980966 | /viewarticle/980966 | [
{
"authors": "Bashar Sharma, MD; John W. Birk, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatmen... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1719264,
"choiceText": "Autoimmune pancreatitis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,... |
926232 | /viewarticle/926232 | [
{
"authors": "Thomas S. Higgins, Jr, MD, MSPH",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment sk... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1478705,
"choiceText": "Nasal polyposis related to allergic fungal rhinosinusitis",
"correct": false,
"displayOrder": 1,
"explanation... |
980564 | /viewarticle/980564 | [
{
"authors": "Benjamin Scott Harris, MD, MPH; Thomas Michael Price, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your di... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1717130,
"choiceText": "Congenital adrenal hyperplasia",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel":... |
867089 | /viewarticle/867089 | [
{
"authors": "Juan Carlos Munoz, MD; Carmela Monteiro, MD; Ivan E. Rascon-Aguilar, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recogniz... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 996039,
"choiceText": "Incidental esophageal food impaction",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLa... |
827431 | /viewarticle/827431 | [
{
"authors": "George T. Griffing, MD",
"content": [
"Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills usi... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 742825,
"choiceText": "Primary amenorrhea",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
979595 | /viewarticle/979595 | [
{
"authors": "Ryan J. Cole, MD; Christopher P. Holstege, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic an... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1713453,
"choiceText": "Lithium-induced hyperthyroidism",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel"... |
889050 | /viewarticle/889050 | [
{
"authors": "Francesco Brigo, MD; Giampaolo Tomelleri, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic an... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1160278,
"choiceText": "Right internal carotid artery dissection",
"correct": true,
"displayOrder": 1,
"explanation": "",
"hi... |
979164 | /viewarticle/979164 | [
{
"authors": "Amber M. Bokhari, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1711237,
"choiceText": "Toxoplasmosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"... |
881807 | /viewarticle/881807 | [
{
"authors": "Unnikrishnan Pillai, MD; Jameel Muzaffar, MD; Santosh G. John, MD; Pascale Salem, MD; Philip B. Vaidyan, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonethe... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1114140,
"choiceText": "Hypertrophic cardiomyopathy",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fa... |
752121 | /viewarticle/752121 | [
{
"authors": "Arun Gupta, MD, DNB",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 438907,
"choiceText": "Acute myeloid leukemia",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
877044 | /viewarticle/877044 | [
{
"authors": "Ramy Saleh, DO; Robert Bassett, DO; Alan Lucerna, DO; Wayne Tamaska, DO; James Espinosa, MD; Kumail Kazim; Frederick Barnum IV; Emeka Ezidiegwu",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountere... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1073644,
"choiceText": "Amitriptyline overdose",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
976833 | /viewarticle/976833 | [
{
"authors": "Minh Chung; Eric Warren, DO; Darshan Rola; Brian Zacharias; Jennifer Broyles, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1704463,
"choiceText": "Renal artery stenosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
858606 | /viewarticle/858606 | [
{
"authors": "Alexander B. Norinsky, DO; Andrew Caravello, DO; James Espinosa, MD",
"content": [
"Editor's Note:\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 942123,
"choiceText": "Lemierre syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
885142 | /viewarticle/885142 | [
{
"authors": "Saad A. Shebrain, MD; Hailey Chang, MD",
"content": [
"Editor's Note:",
"The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1135880,
"choiceText": "Acute gastritis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
823046 | /viewarticle/823046 | [
{
"authors": "Sumaira Nabi, MBBS; Mazhar Badshah, MBBS, MD, FCPS",
"content": [
"Editor's Note:\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagno... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 717869,
"choiceText": "Viral encephalitis with Guillain-Barré syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "... |
868041 | /viewarticle/868041 | [
{
"authors": "Derik L. Davis, MD; Ogechukwu R. Menkiti, MD; Brighita Weinberg, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1007343,
"choiceText": "Septic arthritis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
975148 | /viewarticle/975148 | [
{
"authors": "Marwa Saleem, MD; Ahmad Al Maradni, MD; Mahmoud Alsayed, MD; Ricardo Correa, MD, EdD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accura... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1693881,
"choiceText": "Non–islet cell insulin-producing neuroendocrine tumor",
"correct": false,
"displayOrder": 1,
"explanation": "... |
849308 | /viewarticle/849308 | [
{
"authors": "Inas H. Thomas, MD",
"content": [
"Editor's Note:\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 877193,
"choiceText": "Paget disease",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"s... |
885533 | /viewarticle/885533 | [
{
"authors": "Sunny B. Patel, MD; Richa Dhawan, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatm... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1136356,
"choiceText": "Antiphospholipid syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fals... |
845962 | /viewarticle/845962 | [
{
"authors": "Ziad R. Hubayter, MD, MPH",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills u... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 852575,
"choiceText": "Heterotopic pregnancy",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
973953 | /viewarticle/973953 | [
{
"authors": "Catherine Divingian, MD, PhD; Valerie Gironda, MD; Francisco Torano, MD; Jeffrey Jordan, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1688258,
"choiceText": "Chronic obstructive pulmonary disease exacerbation",
"correct": false,
"displayOrder": 1,
"explanation": "",
... |
720150 | /viewarticle/720150 | [
{
"authors": "Vanya Grover, DO; Solmaz Amirnazmi, MD; Robert Graham, MD, MPH",
"content": [
"Editor's Note:\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. T... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 337574,
"choiceText": "Fatty infiltration of the pancreas",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabe... |
842254 | /viewarticle/842254 | [
{
"authors": "Lemi Luu, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the fol... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 831329,
"choiceText": "Ventricular fibrillation",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,... |
847158 | /viewarticle/847158 | [
{
"authors": "Lars Grimm, MD",
"content": [
"Editor's Note:\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 867285,
"choiceText": "Allergic contact dermatitis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
972301 | /viewarticle/972301 | [
{
"authors": "Jennifer Wachala, DO; Dushyant Singh Dahiya, MD; Farah Wani, MD; Asim Kichloo, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accuratel... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1680826,
"choiceText": "<i>Clostridioides difficile</i> colitis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hi... |
893850 | /viewarticle/893850 | [
{
"authors": "Alexander Potashinsky, MD; John W. Birk, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1196708,
"choiceText": "Infectious agent causing gastroenteritis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"h... |
745798 | /viewarticle/745798 | [
{
"authors": "Maria Cristina Bravi, MD, PhD",
"content": [
"Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment ski... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 415589,
"choiceText": "Myocardial infarction",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
971990 | /viewarticle/971990 | [
{
"authors": "Liana Meffert; Daniel Miller, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment s... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1679360,
"choiceText": "Central cord syndrome",
"correct": true,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
971546 | /viewarticle/971546 | [
{
"authors": "Mounika Gangireddy, MD, MBBS",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skill... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1677609,
"choiceText": "Essential thrombocytosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false... |
727941 | /viewarticle/727941 | [
{
"authors": "Kennedy O. Omonuwa, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills usi... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 363778,
"choiceText": "Chronic aortic dissection",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false... |
843818 | /viewarticle/843818 | [
{
"authors": "Elena Cecilia Rosca, MD, PhD; Cristina Dijmarescu, MD; Mihaela Simu, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recogni... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 837663,
"choiceText": "Brainstem stroke",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
833128 | /viewarticle/833128 | [
{
"authors": "Romesh Khardori, MD, PhD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills u... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 777529,
"choiceText": "Dietary indiscretion/stress hyperphagia",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hid... |
753945 | /viewarticle/753945 | [
{
"authors": "Payman Vahedi, MD; Zahra Mohajernezhad, MD; Mohammad Faraji-Rad, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1184000,
"choiceText": "Brain tumor",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"se... |
885563 | /viewarticle/885563 | [
{
"authors": "Abhimanyu Beri, MD; Fadi Abu-Yasin, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and trea... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1136552,
"choiceText": "Acute pericarditis",
"correct": true,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
970288 | /viewarticle/970288 | [
{
"authors": "Avan Armaghani, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using th... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1670349,
"choiceText": "Work-related injury",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
876163 | /viewarticle/876163 | [
{
"authors": "Nicola E. Burch, MBChB, MRCP; Victoria M. Gordon, MBBS, MRCP",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test yo... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1070070,
"choiceText": "Celiac sprue",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"s... |
746588 | /viewarticle/746588 | [
{
"authors": "Syeda Sabahat Mansur, MB BS; Fardidullah Shah, MB BS",
"content": [
"Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagn... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 417751,
"choiceText": "Anorexia nervosa",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
968988 | /viewarticle/968988 | [
{
"authors": "Guillaume Davido, MD",
"content": [
"A 35-year-old man found by firefighters has had a cardiac arrest. He presented with a Glasgow Coma Scale (GCS) score of 6 and symmetrical miosis in both eyes. Naloxone 4 mg is administered, which causes him to wake up. Paramedics then bring him to the... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1665647,
"choiceText": "Tricyclic antidepressant poisoning",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLab... |
869215 | /viewarticle/869215 | [
{
"authors": "Djamil Fertikh, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using t... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1018882,
"choiceText": "Thyroid cancer",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
968993 | /viewarticle/968993 | [
{
"authors": "Kanchan Kaur, MBBS, MS(Surg), MRCS(Edin)",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and tre... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1664970,
"choiceText": "Inflammatory breast cancer",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
889891 | /viewarticle/889891 | [
{
"authors": "Daniel Beardmore, DO; Sonika Loona, MD; Mia Mallon, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your dia... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1170260,
"choiceText": "Ruptured main bronchus",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
727294 | /viewarticle/727294 | [
{
"authors": "Prasenjit Das, MD, MB BS",
"content": [
"Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills u... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 361933,
"choiceText": "Glioblastoma",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"se... |
729365 | /viewarticle/729365 | [
{
"authors": "Mehtap Cakir, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 368110,
"choiceText": "Hypothyroidism",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"... |
898100 | /viewarticle/898100 | [
{
"authors": "Jaime Shalkow, MD; Mayela E. García",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatme... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1232920,
"choiceText": "Choledochal cyst",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
885135 | /viewarticle/885135 | [
{
"authors": "Greg P. Hansen, DO; Christo T. Philip, MD; Larissa I. Velez, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1134048,
"choiceText": "Cushing syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
736108 | /viewarticle/736108 | [
{
"authors": "Lee Neilson, MD; Elena Cecilia Rosca, MD, PhD; Simu Mihaela, MD, PhD; Chirileanu Ruxanda Dana, MD, PhD",
"content": [
"Editor's Note:\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonethele... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 388446,
"choiceText": "Vascular dementia",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
881373 | /viewarticle/881373 | [
{
"authors": "Peter Huynh, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1103900,
"choiceText": "Hereditary angioedema",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
915146 | /viewarticle/915146 | [
{
"authors": "Amanda L. Blackmon, DO, MS; Lauren Pinter-Brown, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnos... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1381206,
"choiceText": "Normal-pressure hydrocephalus",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": ... |
877077 | /viewarticle/877077 | [
{
"authors": "Alfredo Musumeci, MD, PhD; Michele Alzetta, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic a... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1073616,
"choiceText": "Supraventricular tachycardia (SVT)\r\n",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hid... |
882078 | /viewarticle/882078 | [
{
"authors": "Gerard J. Fitzmaurice, BSc, MBBCh BAO; Robin Brown, MD, FRCS; Mark E. O'Donnell, DSEM, MFSEM, MRCS; Fionnuala Mone, MBBCh BAO; Angela McGreevy, MBBCh BAO",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1115308,
"choiceText": "Pneumothorax",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"s... |
832279 | /viewarticle/832279 | [
{
"authors": "Dora E. Izaguirre, MD; Jesus Lanza, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treat... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 774277,
"choiceText": "Autoimmune hepatitis (AIH)",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fals... |
962080 | /viewarticle/962080 | [
{
"authors": "Mark Davis, MD; Nandita Kakar",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skil... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1635247,
"choiceText": "Lipoma",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"selecte... |
717114 | /viewarticle/717114 | [
{
"authors": "Thomas J. Hemingway, MD; Rick G. Kulkarni, MD, FACEP",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagn... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 329777,
"choiceText": "Brugada syndrome",
"correct": true,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
878930 | /viewarticle/878930 | [
{
"authors": "James Robert Brasic, MD, MPH",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skill... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1088550,
"choiceText": "Cornelia de Lange syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
960397 | /viewarticle/960397 | [
{
"authors": "Paige A. Hargis, BS; Katie S. Murray, DO, MS",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1629088,
"choiceText": "Benign prostatic hyperplasia",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": f... |
865890 | /viewarticle/865890 | [
{
"authors": "Manuel Salinas, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using t... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 986341,
"choiceText": "Central nervous system (CNS) toxoplasmosis",
"correct": true,
"displayOrder": 1,
"explanation": "",
"h... |
861792 | /viewarticle/861792 | [
{
"authors": "Andrea Bianchin, MD; Moreno Agostini, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and tre... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 957705,
"choiceText": "Toxic shock syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
957245 | /viewarticle/957245 | [
{
"authors": "Vikramjit Kanwar, MBBS, MBA; Shyam Srinivasan, MBBS, DM",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your dia... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1616449,
"choiceText": "Lead-related neurotoxicity",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
852434 | /viewarticle/852434 | [
{
"authors": "Noah Gudel, DO; Alyn Hatter, DO, MS; Stanley L. Fox, MD; Marilyn W. Edmunds, PhD, CRNP",
"content": [
"Editor's Note:\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important t... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 898331,
"choiceText": "Dermatomyositis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
955983 | /viewarticle/955983 | [
{
"authors": "Dushyant Singh Dahiya, MD; Farah Wani, MD; Tin Wong; Asim Kichloo, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize.... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1612086,
"choiceText": "Acute myocardial infarction",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fa... |
860310 | /viewarticle/860310 | [
{
"authors": "Elizabeth K. Satter, MD, MPH",
"content": [
"Editor's Note:\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment sk... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 950249,
"choiceText": "Granuloma inguinale",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
954850 | /viewarticle/954850 | [
{
"authors": "Paul P. Rega, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1605352,
"choiceText": "Tolosa-Hunt syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
731206 | /viewarticle/731206 | [
{
"authors": "Ajith Goonetilleke, MB BS, FRCP",
"content": [
"Editor's Note:\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment s... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 373030,
"choiceText": "Right-sided lateral pontine stroke (ie, Marie-Foix syndrome)",
"correct": false,
"displayOrder": 1,
"explanati... |
855224 | /viewarticle/855224 | [
{
"authors": "Jun H. Lee, MD; Marc D. Basson, MD, PhD",
"content": [
"Editor's Note:\n\n\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic an... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 917383,
"choiceText": "Crohn disease",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"s... |
857130 | /viewarticle/857130 | [
{
"authors": "Ingrid Chen, MD; Dieu-Thu Nguyen-Khoa, MD",
"content": [
"Editor's Note:",
"The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnos... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 934685,
"choiceText": "Pulmonary embolism",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
840963 | /viewarticle/840963 | [
{
"authors": "Eva Nourbakhsh, MD; Kenneth M. Nugent, MD; Rishi Raj, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 819545,
"choiceText": "Spontaneous retroperitoneal hematoma",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLa... |
948838 | /viewarticle/948838 | [
{
"authors": "Asim Kichloo, MD; Dushyant Singh Dahiya, MD; Farah Wani, MD; Khalil Kanjwal, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately ... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1579251,
"choiceText": "Acute exacerbation of COPD",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fal... |
948069 | /viewarticle/948069 | [
{
"authors": "Maurie Markman, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using th... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1575616,
"choiceText": "Lung",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"selected"... |
878375 | /viewarticle/878375 | [
{
"authors": "John G. Christensen, Jr, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skill... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1085390,
"choiceText": "Hyperdense renal cyst",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
... |
946426 | /viewarticle/946426 | [
{
"authors": "Ankit Raiyani, MBBS, MD, DNB (Hematology)",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and tr... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1568300,
"choiceText": "Protein-losing enteropathy (eg, celiac disease)",
"correct": false,
"displayOrder": 1,
"explanation": "",
... |
843821 | /viewarticle/843821 | [
{
"authors": "Dafina B. Kuzmanovska, MD, PhD",
"content": [
"Editor's Note:\nThe Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment sk... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 838661,
"choiceText": "Complete Fanconi syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false... |
944870 | /viewarticle/944870 | [
{
"authors": "Catherine M. Divingian, MD, PhD; Mityanand Ramnarine, MD; Jeffrey Jordan, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately rec... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1560629,
"choiceText": "Surreptitious cocaine use",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": fals... |
876162 | /viewarticle/876162 | [
{
"authors": "Caroline Tschibelu, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills usin... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1070044,
"choiceText": "Neuroleptic malignant syndrome",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel":... |
907561 | /viewarticle/907561 | [
{
"authors": "Ricardo Correa, MD; Sri Harsha Tella, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and tr... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1316254,
"choiceText": "Hypogonadism",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"s... |
941704 | /viewarticle/941704 | [
{
"authors": "Avnish Sandhu, DO; Pranatharthi Chandrasekar, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1545572,
"choiceText": "\r\nPulmonary infarction with acute pulmonary embolism\r\n",
"correct": false,
"displayOrder": 1,
"explanatio... |
939915 | /viewarticle/939915 | [
{
"authors": "Joshua J. Solano, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1536910,
"choiceText": "Angioedema",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"sel... |
939533 | /viewarticle/939533 | [
{
"authors": "Melba Estrella, MD; Alan Snyder; John Plante; Dirk M. Elston, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Tes... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1535597,
"choiceText": "Herpes simplex virus infection",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel":... |
842258 | /viewarticle/842258 | [
{
"authors": "Winston W. Tan, MD; Matthew Tan",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment sk... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 831357,
"choiceText": "Sarcoidosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,
"sel... |
938423 | /viewarticle/938423 | [
{
"authors": "Timothy D. Murphy, MD",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1529064,
"choiceText": "Behavioral insomnia of childhood\r\n",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideL... |
904350 | /viewarticle/904350 | [
{
"authors": "Gregory Taylor, DO; Michael Semple, DO; Matthew Warpinski, DO",
"content": [
"Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test y... | [
{
"answered": false,
"answeredCorrectly": false,
"branch": false,
"choices": [
{
"branchPath": null,
"choiceId": 1281940,
"choiceText": "Splenic vein thrombosis",
"correct": false,
"displayOrder": 1,
"explanation": "",
"hideLabel": false,... |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.