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Miscellaneous thoughts and ramblings
Sunday, May 22, 2005
Part 5 of 5: If I could be a doctor...
If I could be a doctor (I could, and I am), I would have to periodically update my Continuing Medical Education (CME) and my certification to prove to myself, my patients, and various government agencies that I still know a thing or two about a field that changes all the time.

Being a horrible procrastinator, I always fall very far behind with anything that isn't due in the next eight minutes. So with CME which is due every two years, I've fallen about two years behind, and with recertification, I don't even want to talk about it. So after a kick in the pants helpful encouragement from ball-and-chain and Psychotoddler, I sat down and scheduled specific times in which I would catch up on my educational obligations.

The nice thing is that nowadays I can do all of it on the web. A Giant And Highly Reputed Internal Medicine Organization has a series of open-book tests that we have to take. We're allowed to use any information source, even colleagues. The goal isn't to trick us to get the wrong answer; the goal is to make us learn some medicine while searching for the right answer.

Let's work through a question together, shall we?
Question 5

Two men dined at a restaurant where they each had onion soup, a salad, grilled tuna, steamed vegetables, cheese, and coffee.
What? Hold it right there! This is an important clue. Grown men only go out to dinner and share all of their dishes if (1) they are at a Chinese restaurant (not that there's anything wrong with that), or if (2) they are lovers (not that there's anything wrong with that). Since they are clearly not having Chinese food, we must deduce that they are sharing bodily fluids. Immediately I skip the rest of the question and look at the choices to see if any of the choices are diseases which are more common in men who "go out to dinner" with men.
Which of the following is the most likely cause of their symptoms?

(A) Scombroid fish poisoning
(B) Ciguatera fish poisoning
(C) Clostridial food poisoning
(D) Bacillus cereus food poisoning
(E) Reaction to tyramine
Huh!? Not only, as far as I know, aren't any of these especially prevalent in very well dressed men who accessorize, but I've never even heard of A, B or D. Looks like I'll have to actually read the rest of the question.
Two men dined at a restaurant where they each had onion soup, a salad, grilled tuna, steamed vegetables, cheese, and coffee. They shared a bottle of wine.
Hmmmm... Still sounds romantic to me, and red wine can cause a idiosyncratic tyramine reaction. OK. Keep reading.
As they completed the meal, both men began to have severe headache, intense flushing, urticaria, palpitation, nausea, and abdominal cramping. One man also had bronchospasm and tightness of the throat.

Which of the following is the most likely cause of their symptoms?
Ahhh… It looks like the whole homoeroticism thing was a red herring. The reason we are told that two of them dined together is because they both got sick, so that eliminates idiosyncratic reactions. Cross out E. So they both got sick because they got some kind of food poisoning, but of A through D, I've only heard of C, and this is nothing like it. They're having a histamine reaction. Looks like I need help from the website of Yet Another Giant And Highly Reputed Internal Medicine Organization. Let's see if they can point me to an article. Aha! Look at this:
Infectious Disease Clinics of North America 1987 Sep;1(3):665-76.

Intoxications from the seas: ciguatera, scombroid, and paralytic shellfish poisoning
There's an article you don't read everyday.
Sporadic cases and outbreaks of intoxications borne by fish and shellfish have increased in frequency during recent years. Ciguatera, scombroid, and paralytic shellfish poisoning account for nearly 16 per cent of all reported foodborne outbreaks of disease in the United States.
Blah, blah, blah. Skim...
Scombroid fish intoxication resembles histamine poisoning and may be treated effectively with antihistamines.
Yay! The answer is A!

Only 55 more questions to go.

And that completes the fascinating "If I could be…" challenge that Psychotoddler punished me with. So to which three lucky slobs do I pass the plague challenge? To no one. My conscience is clean. I'm taking this little socially transmitted disease to the grave with me.

My previous reflections on doctoring:

Going Around
What Is It?
The Secret To Longevity
Thank You, Doctor
Senior Sadness
Dr. Bean,

Are Ciguatera or Scombroid common in the pellagic tuna species? If these were "kelp bass" or Barracuda I'd be more inclined. I'd opt for the much more common histamine reaction (your first inclination), which is well known among tuna fishermen, who sometimes don't cool their frequently abundant catches quickly enough. Ask Nomad what a night of that feels like. When are you and your family going to come up to the ranch and see what this is all about?

Nomad's Pops
Sorry, the answer is actually

F) Never go against a Sicilian, when DEATH is on the line!

Here's the next question:

A Priest, a gorilla, and Raquel Welch walk into a bar...
What's urticaria?
Nomad’s Dad: It’s great to read you here! I swear all I know about these diseases is what I read in that little on line abstract. The only sentences that I left out that might help with your question are:

"Fishborne ciguatera and paralytic shellfish poisoning are characterized by gastrointestinal and neuromuscular manifestations attributable to toxins of dinoflagellates."

They don’t mention the kind of fish that carry the dinoflagellates, but “dinoflagellates” is really fun to pronounce. Thanks for the invite. We’d love to come just as soon as I can actually afford a vacation. I will confer with ball-and-chain. I don’t think you understand, though, that we have four kids and between them, they can rapidly decrease the value of your ranch.

Big hug to Nomad’s Mom, and if you’re ever within 50 miles of LA, you have to visit.

Psychotoddler: Here’s another one for you.
Racehorse walks into a bar. Bartender says “Why the long face?”
pa DUM pum!

Irina: Of all the incomprehensible things in that question, you were curious about urticaria? I should have you take some of these questions for me.
"Scombroid" is now officially my favorite new insult.
Ciguatera sounds like something Ricky Ricardo said when he was angry at Lucy.

Lucy: I thought you'd be surprised if I showed up in disguise at your club!
Ricky: Ay, Dios mio! Ciguatera!
LOL! Actually some of those questions sound kind of fun, especially the descriptions of the effects of the aforementioned poisoning! What's more interesting than to hear about someone's symptoms after they've tried some exotic food you never even heard of???
Was there a bonus question, such as: Did the men sue the restaurant management for their "discomfort" and inability to remain social?
Irina: You've never heard of tuna? Are we looking at the same test question?

Torontopearl: That would have been for the Law Boards, as well as a question about what happens if one of the men is hospitalized, and the other wants to visit him, but can not because the state in which they live does not recognize domestic partnerships.
No, I meant the other weird-sounding fishes.
Although some people would find tuna exotic enough...
Irina: gotcha.
What was the disease old Saul Bellow came down with in the Caribean and nearly died from, something fish-related? He was nursed back to health IIRC by his young, pretty wife or maybe lover.
if one of the men is hospitalized, and the other wants to visit him, but can not because the state in which they live does not recognize domestic partnerships

Has anybody EVER been prevented from visiting their homosexual partner in the hospital, or is that just a complete red herring? Because regardless of morality, it would be really cruel to deny a sick person visits from any loved one they wanted to see.
Um, on second thought, I think maybe that's a straw man, not a red herring.
Dr. Bean,
Thank you so much for your blog! I'm slogging through my internal medicine mod-e-youl and come across the same question. I'm all ready to check tyramine reaction -- you know, the cheese and wine and fish . . . Couldn't be food poisoning -- didn't have diarrhea. But boy was I out to lunch!

Anyway, on to number 52!

Dr. Kinsel :)
Not all are true. Everyone has their own way of thinking but I think they have to reconsider. I like to argue for the most accurate results.

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