Wow! This week’s FFFF features some funtabulous findings that may at first feel frivolous, but — fear not — will help you figure out the furtive factors that are enfeebling your less-than-forthcoming ED frequenters…
Perhaps more than anyone, the emergency physician has an inclination to master the Sherlockian arts of observation inspired by Joseph Bell. After all, we are the ones who most commonly have to make critical decisions with incomplete information about patients who are obtunded, incapacitated, uncooperative or unable to communicate. Fortunately for us all, a Texan named Rais Vohra recently posted a link to a classic article titled ‘The Bedside Sherlock Holmes’ on the International Emergency Medicine (Australasia) Facebook page.
This week, FFFF contains questions inspired by this article on the ‘extracorporeal’ signs of disease. Once you’ve had a go at the questions, be sure to read the entire article which you can access for free by clicking on the PMCID number below:
Fitzgerald FT, Tierney LM Jr. The bedside Sherlock Holmes. West J Med. 1982 Aug;137(2):169-75. PMID: 7135953; PMCID: PMC1274053.
Fitzgerald and Tierney begin their article with this excerpt from ‘A Study in Scarlet’ by Arthur Conan Doyle:
SHERLOCK HOLMES: “Let him, on meeting a fellow mortal, learn at a glance to distinguish the history of the man and the trade or profession to which he belongs. By a man’s finger-nails, by his coat-sleeve, by his boot, by his trouser knees, by the callosities of his forefinger and thumb, by his expression, by his shirt cuffs-by each of these things a man’s calling is plainly revealed.”
JOHN H. WATSON, MD: What ineffable twaddle!”
Questions
Q1.”Bizarre combinations of color in otherwise conservative clothing” hint at what condition in a man?
- Colo(u)r blindness
- The authors warn that ‘in all of these assessments, however, an examiner must take in to account the vagaries of American taste.”
Q2. What is the differential diagnosis of a black stool stain on a patient’s underwear?
- “A black stool stain can suggest melena, but can also reflect a patient’s use of iron, charcoal, bismuth, black cherries or even licorice ice cream.”
- Also, don’t forget to look for the silver stool of carcinoma of the ampulla of Vater (apparently an admixture of melena and acholic steatorrhea) and the ‘dramatic smoking stools‘ of (white/ yellow) phosphorus poisoning.
Q3. A woman presenting with weakness has a handbag filled with licorice wrappers. What is the likely cause of weakness, and what other findings would confirm your deduction?
- Excessive licorice consumption.
- Weakness may result from:
- hypokalemia — licorice contains glycyrrhizic acid which is structurally similar to aldosterone and can cause hypokalemia, hypertension and other features of mineralocorticoid excess.
- licorice myopathy and myoglobinuria.
Q4. What conditions should be suspected in a woman who makes heavy use of eyebrow pencil when applying her makeup?
- Eyebrow pencil may be used to conceal the loss of eyebrow hair in conditions such as:
- hypothyroidism
- leprosy
- syphilis, or
- systemic lupus erythematosis
Q5. Patients with which disease are said to smell like ‘freshly baked bread’?
- Typhoid fever
- If you think you’re a real olfactory Sherlock Holmes try the ‘Sniff a Poison’ Challenge.
Parting Piece of Funtabulous Wisdom…
Pizza can turn anyone into a mathematician!
About Chris Nickson
You forgot to mention the black stool a few pints of Guinness inflicts!
Michael, thanks for imparting us with what I’m sure is a hard won piece of wisdom.
C
I once thought I had melena and was a goner. Then I remembered I had dined on squid cooked in its own ink the night before. The ink passed through unabsorbed and scared the crap out of me (so to speak).
That’s a classic Leon! I s’pose next time you have a blocked nose you’ll think you’ve been bitten by a red-bellied black snake…
C
Don’t forget the dark red post-beetroot look -- that scared the crap out of me once!
Heavy use of eyebrow pencil in a woman may also be a sign that she really is a blonde…or even an albino.