Part 18: Episode 18: Moving Heart

This update covers:

Gabriel Cunningham 4 - Moving Heart (Part 1 of 2)



You already saw the opening to this one two episodes ago. It doesn't really have much to do with the case yet, anyway.

RONI: Well then, Doctor. Let's begin today's diagnosis. The patient, Shelly Brooks, claims to have a fever. Dr. Cunningham, are you listening?

Gabe: Hm? Yeah.

RONI: Does Secretary Tillman's operation weigh heavily on your mind? IF you are troubled, I am equipped to listen.

Gabe: *sigh* They even gave you a consultation function, huh?

RONI: No, but I can supply template responses to match your mood.

Gabe: That's just pity comfort. Come on, start the diagnosis.



Gabe: Not a problem. Now, to begin with...

Shelly: Um, I'm sorry, Doctor, but I have to attend an important business deal soon. Is it possible to keep this as quick as you can? Please?

Gabe: Well, I wasn't planning on wasting time.



Shelly: You can't? Oh, dear. This isn't good. I've got a meeting soon. Um, I've had a fever for awhile and it won't go away. I've also lost some weight, but I think it's just because of the fever. Besides that, I've been having night sweats, but that might just be the fever, too. I can't think of anything other than those... oh! I wasn't trying to hide this or anything, but I had an operation two months ago. It wasn't at this hospital. I had some kidney trouble, and received a transplant. There are some odd bruises around the scar from the operation. It's strange, I made sure to take the medication they gave me. But that's it, really. See? It's just a cold, right?

For once, we have a patient who gives us a straightforward answer. First, the fever.

Gabe: A continuous fever, huh? Perhaps... Excuse me, but are you married?

Shelly: Is that relevant to my illness?

Gabe: Well, there's no direct relevance, but a woman's body temperature increases during pregnancy. We see a lot of women who think it's a fever.

Shelly: Oh, ahaha... Well, thank you for thinking about that. No, I'm totally concentrating on my job right now.

Gabe: I see. Then, let's make a note of this, RONI.

RONI: New Symptom: "Fever."

In addition, she mentioned weight loss.

Gabe: Whether this is a symptom or not depends on how much you lost. What was your original weight, and what is it now?

Shelly: Um, I really don't want to mention how much.

Gabe: Okay, you don't have to be specific. Ballpark it?

Shelly: ...It seems like a lot. Like it's more than should be natural.

Gabe: I appreciate your cooperation. RONI, jot that down.

RONI: New symptom: "Weight Loss."

In addition, she complained of night sweats.

Gabe: Well, Dysautonomia is the first thing to come to mind, but... Well, you've been busy with work, right? Does it stress you out?

Shelly: That's a good one, Doctor. I love my job!

Gabe: You're a strange one. If I had my pick, I'd be sitting on my couch all day.

RONI: That's not relevant, doctor. New symptom: "Night Sweats."

Gabe: Alright, already. You're starting to sound like my wife.

Finally, and most interestingly, odd bruises around her scar.

Gabe: That worries me a little... Could you tell me in detail where they are and what they look like?

Shelly: The scar healed cleanly, so there isn't much of it left, but there are these black, bruise-like things around where it was.

Gabe: I'll need to look at it later. Would you mind showing me?

Shelly: If it's for the examination, I understand.

We can take a look right now, in fact.



Gabe: There are dark red pigment spots around the operation scar. Did they exist before the operation?

Shelly: No, I'm sure of it.

Gabe: Did you show these to your doctor? What did he say about it?

Shelly: This is the first time I've seen a doctor since the operation. I've been too busy to keep an appointment.

Gabe: Then this needs to be examined. RONI, I'll need a scintigraphy and a biopsy done.

RONI: Since biopsies are done in the pathology department, it will take some time. Is this acceptable?

Gabe: Well, if it's not in our department, I can't tell them to do it right away. Just let me know when the results come back.

RONI: Understood, doctor. New Symptom: "Pigment Spots."

...I guess I'll just get this out of the way.



Alrighty, so we can go check the scintigraphy now. We can also auscultate, but it doesn't actually turn up with anything.

RONI: Doctor, this is the patient's thalium intake in the entire body.

SCINTIGRAPHY_01
Patient:



Sample:



It shouldn't be too hard to see this one: there's an unusual spot in her abdomen. You can see it in the front-facing picture (left).

Gabe: The uptake of thalium matches the pigment spots in the skin. There's a good chance the spots are tumors. We should review our diagnosis candidates.

RONI: New symptom: "Abnormal Intake into Pigment Spots."

And we're already ready to check out the candidates.



Symptom List:
Pigment Spots
Abnormal Intake
Night Sweats
Weight Loss
Fever

Pityriasis Rosea is obviously not correct, as it only has four symptoms. Malignant Melanoma, too. Between them is a possibility, though.

Erythema Multiforme:
A skin disease caused by viruses. An outbreak of this is accompanied by the appearence of symmetrical pigment spots on both sides of the body. [snip]

That doesn't describe ours. Next!

Kaposi's Sarcoma:
A type of malignant skin tumor caused by caused by human herpesvirus 8. The patient exhibits symptoms including fever, weight loss, and night sweats. A visual exam will confirm the presence of pigment spots. A scintigraphy will find abnormal uptake in areas of heavy pigmentation, and positive antibody reaction will be seen. This disease only appears in humans when an extreme decrease in the immune system has occured, due to AIDS or other immunity-altering situations, such as some medications.

This one fits.

Gabe: All our symptoms apply to it, but there's no way this could have happened unless there was an extreme decrease in the immune system. If we don't solve that, it's impossible to make a diagnosis. I feel like it's right in front of me. RONI, do you remember anything that might help?

RONI: I record only pertinent details in my memory. Would you like me to record every detail of the diagnosis?

Gabe: No, I feel like I'd be cutting off all of my escape routes if I did that.

Gabe still has an awful memory. The patient had a transplant, and was taking medication. Immunosuppressive drugs are normal after a transplant. As usual, we have to spell this out for him by going back to the patient.



Shelly: Nothing has changed in particular. Is this going to take long?

Gabe: Don't get so hasty. It's going to take a little more time.

Shelly: I see. I have a meeting soon, though...

You now have to question her again and select the bit where she mentioned taking medication.

Gabe: Hey, I'm sorry, but I need to confirm something. You were given immunosuppressive drugs, right?

Shelly: Yes. Isn't that normal after a transplant?

Gabe: Yeah, that's right, but it's something we need to know when making a diagnosis. Now, everything depends on the results of your biopsy.

RONI: Dr. Cunningham, the biopsy results have come back from the pathology department. The antibody reaction was positive, but they failed to specify the virus causing the disease.

Gabe: What? What in the world are they doing?

RONI: The reason is unknown, Doctor. Shall I explain the 1,874 patterns of conjectures in regards to it?

Gabe: Uh, what? No, that's alright. It shouldn't be a problem to make a diagnosis.

We have the final symptom, the positive antibody reaction. This confirms our guess.



Gabe: But why? The period of time until onset is too short. It's similar to Kaposi's Sarcoma, but this is something else.

RONI: Doctor, we have an urgent contact. Please head immediately to the examination room. The patient has come to the hospital complaining of abdominal pains.



Gabe: What the hell is going on?

RONI: Doctor, these may be related to the tumors discovered before.

Gabe: Reserve an OR just in case. Let's begin.



Shelly: Well, I went to work, but my stomach started hurting all of a sudden.

Gabe: There's a chance your condition took a turn for the worse. RONI, get ready for examination.



Shelly: And I feel a little nauseous, too. I can't concentrate on my work with this going on. Please, Doctor. See if there's anything wrong with me. Let's see... if there's anything else worth mentioning, I guess I've been feeling a little bloated. Lately, um, I haven't been able to, um... I'm having trouble using the bathroom fully. You understand?

A bunch more, but they're still straightforward. The abdominal pain is the obvious reason she's here.

Gabe: So these are the sudden abdominal pains you mentioned earlier. RONI, make a note of it.

RONI: New symptom: "Stomachache."

Gabe: She's experiencing nausea, as well. This is far from being good. RONI, make sure you're getting all of this.

RONI: New symptom: "Nausea."

Gabe: Her abdomen is bloated, too. RONI?

RONI: New symptom: "Bloated Abdomen."

And then we have to tackle her bathroom problem.

Gabe: Well, let's just be frank about it. There's nothing to be embarrassed about. We're animals. We excrete waste. ...Alright, I won't force you to say it, but you're unable to produce those things in the toilet, yes?

Shelly: Y-yes.

Gabe: Great, now we're getting somewhere.

RONI: New symptom: "Constipation."

Now, we need to auscultate. Luckily, there's actually something worth finding this time.

Auscultation Video
Viddler
Youtube

Her gut sounds like a raging beast, so, yeah, we have the new symtom "Aggrevated Bowel Sounds."

Gabe: Given these symptoms, it appears to be a problem with the intestines. RONI, get approval for X-ray and CT scans.

RONI: I've already sent in the requests, doctor.

Gabe: Good call. Maybe you should become a diagnostician.

RONI: With all due respect, Dr. Cunningham...

Gabe: I was just joking. Let's hurry up and get going.

We now have FIVE new images. To start with, we'll check the X-rays.

X-RAY_01
Patient:



Sample:



The difference here is easy enough. There's an unusual shadow in the middle of the picture. It's shaped... kind of like a telephone. That's what I'm going with.

Gabe: The fluid and gas in her intestine have completely seperated. It's a niveau, RONI. An air-fluid level. Write it down.

RONI: New symptom: "Formation of Air-Fluid Level."

Now, the CT scan.

CT_01
Patient:



Sample:



CT_02
Patient:



Sample:



CT_03
Patient:



Sample:



CT_04
Patient:



Sample:



One difference is very clear in the second picture, but you'll notice those are her kidneys. It's actually a very easy medal challenge!

Gabe: Atrophying can be seen in the left and right kidneys...

RONI: Doctor, the patient has received a kidney transplant.

Gabe: Oh, right. I forgot the new kidneys were transplanted without removng the old ones. I guess this symptom's already been treated. ...Just testing you, RONI.

The REAL difference is in image number 4. There is a large white spot in the upper-right. Allow me to highlight it using state-of-the-art image enhancement techniques.



Gabe: It's hard to make the call. RONI, give me your opinion on this.

RONI: I do not have opinions. My answers are based on statistics.

Gabe: Whatever, just spill it.

RONI: My calculations show an approcimately 92% chance that these are tumors.

Gabe: Woah. Okay, let's just call them tumors for now.

RONI: We cannot do that, Doctor. There remains an 8% probability that they are not tumors.

Gabe: ...Which pretty much means they're tumors. Just record the symptom.

RONI: New symptom: "Tumor Shadows on Small Intestine."

Gabe: Now, let's go back to my office and sort this out.



Now then, this is a short section, so we're already back at the stage of making a diagnosis. Let's take a look at the data.

Symptoms:
Tumor Shadow
Air-Fluid Level
Aggravated Bowel Sounds
Constipation
Bloating
Nausea
Stomachache

Paralytic Ileus:
A condition in which the contents of the intestine have been obstructed by the motor paralysis of the intestinal tube. Symptoms such as stomach pain, nausea, constipation and abdominal bloating appear. Auscultation will confirm a lack of bowel sounds. [snip]

That's the opposite of what we heard, but the subjective symptoms are the same. What we're looking for is similar to this.

Occlusive Ileus:
A condition in which the intestinal tube narrows or becomes blocked, obstructing the intestine. This is accompanied by symptoms such as stomach pain, nausea, constipation and abdominal bloating. Auscultation will reveal aggravated bowel sounds. The formation of an air-fluid level can be seen on an X-ray scan. Also, tumor shadows of the blockage will appear on a CT scan.

This one has everything. For once, we don't need to run any more tests, either.



Gabe: An intestinal ileus originating from tumors in the small intestine.

RONI: Due to the location, there is a high probability that the primary focus will be the ones on the skin.

Gabe: Dammit, I know, but...

RONI: Doctor, I recommend that you examine the other organs as well.

Gabe: Yeah, I agree. Let's go back to the exam room.

Next time: The conclusion of Moving Heart.

Medal Challenge Answers



 C 



 A 



 D 



 D 



 B