Wow. Just wow.

So we had a standardized patient interview group meeting this week in PPS (patient physican and society). What we do is sit in a group, one of us interviews an actor playing the patient, we discuss possible diagnoses together, then someone else talks to patient about the diagnosis and possible treatments. This week's subject was diarrhea. The following story was related to me by my friend in whose group the following events transpired.

Our protagonist elicits the following history:
The patient is a 2 year old boy. His hispanic father relates the following history: patient has had watery diarrhea for the last 12 hours. The family had eaten together at a church picnic where chicken, warm rice, and other potluck foods were served. 5 hours later, the patient, and some of his family members all reported having intermittent non-bloody, non prurlent diarrhea.

Even the most un-medical lay person would probably leap to the diagnosis of food poisoning, specifically, some toxin mediated form (B.cereus, S. Aureus, or some other form). The history fits, the signs and symptoms fit, and the diagnosis is, in fact, food poisoning. You might also consider some viral gastroenteritis, but since the whole family is simultaneously sick in such short order, the illness is more suggestive of food poisoning. Now is when our hero shines.

When queried by the moderator about possible illnesses to include in the differential, our hero says:
"well, I feel that, it's , you know, like maybe esophageal atresia. Maybe it's like, like, a fistula, you know? like a tracheal-esophageal fistula? Or maybe, you know, I can't remember what it's called (now he waves his hand vaguely over the right upper quadrant of his abdomen), you know, like some hypertrophy of something? the duodenum? "
"Pyloric stenosis?" asks the moderator, dumfounded.
"yeah" replies the champion.
"NO." says the moderator, floored at the ignorance of our protagonist.

Now, some vocabulary for you so you can understand the colossal mistake that our protagonist made.

• Esophageal atresia: when the esophagus forms in the embryo, it initially forms as a solid structure which then hollows out. If the hollowing out is incomplete, you have esophageal atresia. In other words, the esophagus is a blind-end tube. The first meal that the baby attempts to take after birth would, of course, not reach the stomach. No way this would happen in a 2 year old. Most of all, this COULD NOT, by definition, cause diarrhea! (not to mention everyone in the family? simultaneously?)

• Tracheal-esophageal fistula: an aberrant connection between the trachea and the esophagus, again from an error during embryogenesis. Also, this would have been evident during the neonatal period. Again, not a cause of diarrhea.

• Pyloric stenosis: The scar on my abdomen attests to my experience with this. In this condition, the pylorus, which is the connection between stomach and the uppermost portion of the small intestine, closes due to overgrowth of the sphincter muscle found there. Typically, this presents in first born males in the first month or two of life. Characteristically, there is projectile vomiting. Since the GI is closed by the hypertrophied sphincter, of course no food is reaching the colon to become diarrhea.
  

I'm amazed at how wrong his diagnoses were. Come on! the conditions he described, for the most part, are obstructive and would not, could not, result in diarrhea!! Not to mention that common sense alone would tell you it's food poisoning (though you might have to have microbiology to tell which bug is the likely culprit.) This dude is one of the SLU medscholars, who were selected as college freshman for automatic entrance into medical school, as long as they kept their grades up in undergrad. Simply stunning.