Solve the Medical Riddle: Her Daughter Feels as Though the Room is Shrinking, Second Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

Last week, the patient reported her daughter’s symptoms and the doctor proceeded with the examination. That was step #1, S, of the classic S-O-A-P notes as follows:
S=Symptoms or Chief Complaint
O=Objective Findings
A=Assessment or Analysis
P=Treatment Plan or Recommendations

This week the doctor will move on to O and A in order to continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will move on to P to reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Looks for Clues to the Medical Riddle

O=Objective Findings

When Marlene brought her daughter Chloe in for an appointment, the doctor took a complete history and ruled out many possible causes of the disturbing episodes during which the room seemed to be shrinking and some colors appeared to be changing in addition to severe fatigue.

O: Objective:
Moving on to “O”, the doctor asked Marlene to take Chloe to an ophthalmologist for a complete eye exam.The eye care specialist found nothing amiss with Chloe’s eyes.

Chloe then returned for a complete physical exam with the PCP. During the exam, the doctor discovered that Chloe had painless but swollen lymph nodes behind her ears and groin. Chloe also had an enlarged spleen.

A=Assessment or Analysis
At this point the doctor suspected infectious mononucleosis, often called the “kissing disease”. Mono can have relatively mild symptoms. Yet it may have neurologic ones because it infects the brain. The doctor told Marlene and Chloe that mono is not highly contagious but that living in close quarters such as a dorm could spread it, as could kissing. Chloe blushed and admitted that she had a new boyfriend at college that she hadn’t mentioned to her parents. “We haven’t done anything but kiss and I don’t think he has mono!” Chloe said. Marlene smiled and said she was glad to hear about the boyfriend. The doctor said that Chloe could have contracted mono at the dorm.

The doctor drew a blood sample for a complete blood count and sent it to a lab. The result was that Chloe’s white blood count was elevated about 18,000 with 12% atypical lymphocytes. This indicated cells fighting the mono virus, which is classic for mono. The mono test was positive and Epstein Barr virus acute antibody was positive.

The doctor mentioned that he was glad he had tested for mono rather than suspecting step throat and prescribing ampicillin, as sometimes happens. Within hours of a dose of ampicillin, a diffuse red rash occurs. For some reason this is pathognomonic for mono – meaning specifically characteristic or indicative of a particular disease or condition. Ampicillin triggers the rash but this does not mean that the patient is allergic to penicillin or ampicillin but rather that the patient has a peculiar response to mono and the drug. The doctor said he had seen this many times.

Yet even with a diagnosis of mono, the riddle of the shrinking room had yet to be solved. The doctor ordered an MRI, which turned out to be normal, and an electroencephalograph (EEG) that ruled out seizures. The quest for a diagnosis continued . . .

To be continued . . .

Come back to ThirdAge.com next Thursday to find out what some people have guessed the diagnosis might be.
Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Pleas visit DrSavard.com