A Caucasian male, aged 33 years, with a history of post-traumatic stress disorder, hypertension, and gastroesophageal reflux presented to a tertiary care center with a two-day history of severe nausea and intractable vomiting. The vomiting began with no identifiable precipitating factor, was bilious but nonbloody, and occurred as frequently as six times per hour. The patient reported abdominal pain and lightheadedness secondary to dehydration but denied any fever, coryza, change in bowel movements, or sick contacts.The patient had been experiencing similar episodes recurrently for the past 2 years, frequently associated with life stressors and requiring five previous hospitalizations. He had received an extensive work-up, including laboratory tests, kidney-ureter-bladder radiograph, computed tomography of the abdomen, abdominal ultrasound, gastric emptying study, and esophagogastroduodenoscopy. All tests returned negative for identifiable pathology, with the exception of electrolyte disturbances secondary to protracted emesis. As a result, the patient was diagnosed with cyclic vomiting syndrome.Notably, however, the patient had been an intermittent, recreational marijuana user for many years prior but had escalated to daily use over the past 2 years for symptom relief, citing the known antiemetic effects of cannabis. In addition, he described a compulsive pattern of bathing, stating that he often felt nauseated when having bowel movements and had discovered that transitioning directly from the toilet to a hot shower helped resolve his nausea. He described turning the shower temperature to a maximum, noting that it felt as though the hot water washed away his nausea. The patient often required several such showers per day and had been doing this for at least one year.His home medications included only citalopram and omeprazole. Family history was non-contributory. The patient drank two beers daily and had a history of Keywords: Cannabis; Cyclic vomiting; Hyperemesis; Marijuana Cannabis is the most widely used illicit drug in the United States, with lifetime prevalence of use estimated at 42% to 46%. The antiemetic properties of cannabis are well-known by the medical community and the general public; however, less well-recognized is the paradoxical potential for certain chronic users to develop hyperemesis. We describe in this case a patient with prior extensive work-up for nausea and vomiting and previous diagnosis of cyclic vomiting syndrome who presented with characteristic features of cannabinoid hyperemesis syndrome. We review the current literature for this condition and highlight potential mechanisms for its pathogenesis.
Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.
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