Case Presentation

The setting: MS-2 year, Sahuaro Hall.
Present: MS-2 class, Dr. Finch in a sweet blue Hawaiian button-up shirt and his wavy blonde hair that needed to be cut about six months ago.
Dr. Finch: Ok guys, it's time to do another ICM case. This was submitted to me from a Dr. Jensen in Wray, Colorado. I'll start out by giving you guys some pertinent information, and I want you guys to come up with a differential diagnosis.
CC: "I can't poop"
HPI: 32 year old Mexican male with no past medical history is brought into the ED by his wife and family in moderate distress. He states that he awoke this morning around 2 AM with abdominal pain in his LLQ. It comes and goes, he is unable to describe the character of the pain. It's worse with standing upright, relieved by lying down. He notes that the pain has moved from his LLQ to his RLQ over time. He admits to some rectal bleeding this morning when attempting a bowel movement. He also admits to some nausea, but no vomiting.
PMH: None
PSH: None
Meds: None
Allergies: None
Social: No tobacco, had some drinks at a friend's home last evening.
ROS: No fever, chills, otherwise as above.

Dr. Finch: Okay guys, what is your differential?
Number 2: GI Bleed
Finch: Ok, good
Damon: (says to Jeremy, "That number 2 is a real prude. It's clearly appendicitis.") Appendicitis
Finch: Good Damon, what else can we come up with?
Caywood: How about a butt tumor?
Finch: You mean like an adenocarcinoma?
Caywood: Sure.
Kevin: Tapeworm
Finch: How do you figure a tapeworm into your differential?
Kevin: When I was a cop up in the Northwest I saw a guy with this same presentation who we did a drug bust on and we ended up hauling him in to the ED and he had a tapeworm.
Finch: Okay, if you say so.
(Kevin shakes his head in disgust)
Slice and Dice: What about a diverticulosis or diverticulitis? See, I spent nine years in the OR and I saw this kind of thing all the time. We cut guys open all the time for abdominal pain; maybe he needs surgery.
Jeremy: How about an abnormal skin lesion?
Brizzee: Psoriasis?
Finch: All right, you guys are getting way out in left field here, let's redirect. LLQ pain moving to the RLQ, nausea, comes and goes, what else do you guys want to know?
Trent: It could be a kidney stone or even a testicular torsion.
Finch: True.
Fake Tarmac: How about a Suave deodorant bottle stuck in this guy's rectum?
Finch: How in the crap did you guess that?
Fake Tarmac: Just a feeling I've got.
Finch: Yup, that's right. And here's the x-ray to prove it.

So what's the rest of the story? I went through a 15 minute HPI with this freaking guy on the interpreter phone and finally at the end of it he said, "Last night I went over to a gay friend's house and we had some drinks. I passed out and I think he put something up there."
Ok, so if only he had come into the ED and said, "I think I have a deodorant bottle shoved up my butt" it would have made things a lot easier. Needless to say, the rectal exam revealed a round plastic object high up in the rectum. I tried like the dickens to get the sucker removed, but ended up needing to transfer him so that GI could do the dirty deed.

If anyone really wants to see the x-ray, just email me, not sure if I should post it on the web.

Have you ever met a proctologist? Well, they usually have a very good sense of humor. You meet a proctologist at a party, don't walk away. Plant yourself there, because you will hear the funniest stories you've ever heard. See, no one wants to admit to them that they stuck something up there. Never! It's always an accident. Every proctologist story ends in the same way: "It was a million to one shot, Doc. Million to one."