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Patient Encounters

Memorable Patients

In my medical career, there have been a handful of patients that I remember well. Like frames on a storyboard, when I think back upon the tens of thousands of patients I have treated, these patients always seem to come to mind. Perhaps as a precursor of things to come, I even wrote stories about some of them early in my career when I saw them. I remember the first time that I drew blood on an elderly patient and how it seemed like her room was a prison cell. I’m sure she passed away a long time ago, but I can still remember looking into her eyes and wondering what this poor woman had been through in her life. I remember one of the first surgeries that I was asked to scrub in on during my Ob/Gyn rotation. They called it a “TOP”. I was excited to be a part of it. Then I learned that “TOP” stood for “Termination of Pregnancy.” I remember feeling uneasy as the resident showed me how to use the currette. I remember almost passing out when I looked through the speculum and saw a tiny white hand laying across the red surface of the patient’s cervix. I remember almost vomiting as a resident as a nurse told me that an intoxicated patient with dizziness just needed to “sleep it off” … right before he vomited a liter of blood all over her and over the curtain a couple of feet behind her. And of course there was the lollipop lady. I wrote a post about her already. Recently another patient was added to the storyboard of my medical career. I’m not sure if there was anything so memorable about her, but perhaps it was her blase demeanor in the face of a rather messy problem. Well … you can decide. The patient was in her mid- to late-60s, was well spoken, pleasant, and well-kempt. She had changed into a gown and her clothes lay neatly folded on the chair across the room. Her problem was a regulation of her bowels. First, she had diarrhea for a couple of days. She took some Imodium and Pepto Bismol and the diarrhea stopped. But then she had no bowel movement for two days. That was to be expected since after diarrhea stops it often takes the body a day or two to create more stool. The patient became concerned after having no bowel movement on the second day and she took a laxative, thinking that she may have a bowel obstruction. Then she had black colored diarrhea. Her stool was hemoccult negative, meaning the black color was likely from the bismuth in the Pepto Bismol. Bismuth combines with small amounts of sulfur in your GI tract and can turn your tongue and your stool black. Examining her closer showed that there was dried black crust all of the way down the inside of both her legs. She had passed enough diarrhea that her buttocks had become inflamed and it hurt when she sat down, so she preferred to lay on her side. She got a liter of fluid, we got a CBC, chemistries, and a stool sample just to make sure there wasn’t an infectious etiology for her symptoms and that she didn’t have a metabolic acidosis. Everything was normal. Then the strangeness began. I went back into the room to see how the patient was feeling. I could hear the lid on the infectious waste container slamming shut as I entered the room. Then I got hit head-on by a foul smell. I pulled the curtain ...

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The “Unnecessary” Test

Here’s a real case submitted by a reader. A two year old child is brought into the department by her father, her mother, her grandmother, and her greatgrandmother. All were very concerned. The child was walking on a curb using her dad’s hand for support when she lost her balance and fell. Her dad didn’t catch her quickly enough and the child struck the side of her head. The mother said she saw the child’s head “bounce off the concrete”. Both mother and child cried immediately after the accident. After about 10 minutes, they put the child into the car. She went to sleep immediately. The mother tried shaking her leg, but she wouldn’t wake up. The father then stopped the car and they took her from the car seat and shook her. She still didn’t wake up. They called grandmother who called great grandmother. All agreed to meet at the emergency department. When she got to the emergency department, she was alert. In fact, she was running around the room opening drawers and pressing buttons. Both parents had to restrain her just so she could be examined. Even then, she wouldn’t sit still. A thorough exam of her head showed absolutely no signs of injury. She did say “ouch” when the back of her head was palpated, though. Normal pupils. Normal TMs. Normal neck. No Battle Sign. No other evidence of inury. No vomiting. In other words, she met all of the criteria for a “low-risk” head injury (.pdf) except for the parents’ history of this prolonged unresponsive state. Three generations of family members want a CT scan of the brain. The explanation of injury doesn’t match the physical findings and you believe in your heart that the parent’s story of a 15 minute episode of unresponsiveness is inaccurate. You also know that there’s no way that the child will sit still for a CT scan. That means that you’ll have to do conscious sedation (including all the extra paperwork required by the Joint Commission) and observe the child for a couple of hours after the CT has been performed. If you do the test and it’s normal, then you will be accused of performing defensive medicine, the nurses will be pissed at you for the rest of the shift, your productivity will tank, you’ll get an e-mail from your department chair about all the complaints from patients for the long waits, you’ll get bad Press Ganey scores from the upset patients, and you may get a letter from hospital administration for “overutilization” of resources. If you don’t do the test, the family will be upset with you, will accuse you of providing poor medical care, and will give you bad Press Ganey scores (and you’re on the CEOs hit list for the two bad scores you had last quarter). Oh, and if you don’t do the test and the kid has a bleed, you’ll be sued, the chart will show that everyone in the family thought the CT should be done and you were just too dumb to perform it, and the State Medical Board will likely bring a licensure action against you … which could result in you not being able to practice medicine any longer. What do you do? [yop_poll id=”3″] ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me. I’m making full blog posts ...

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The Bloody Knife

Patients seeking refills for chronic pain prescriptions are finding that those requests are being rejected more and more often by emergency departments. Due to the increasing incidence of drug diversion and doctor shopping, many hospitals are developing policies that limit or even prohibit prescription of controlled substances for chronic medical problems. But every time that people build a better mousetrap, Mother Nature builds a better mouse. Patients know that they won’t get prescriptions for chronic pain, so they often come in complaining of acute injuries. Lots of falls down stairs with acute back injuries, lots of twisted ankles, some neck spasms after non-reported car accidents. So not only do the patients get their medications, they often get additional x-rays … which drives up the cost of their medical care. One regular patient was reportedly pretty creative with her acute injury. She came in with significant pain in her thigh after suffering a stab wound. In fact, when she rolled in the doors on the ambulance stretcher, she still had a paring knife sticking out of her leg. Police weren’t called though. The injury was self-inflicted. Turns out that the patient was using a paring knife to make herself a baloney sandwich. While she was standing in the kitchen spreading mayonnaise on the bread, her leg kept twitching. In fact, the twitching got so bad that she had trouble standing upright. So in the spur of the moment, she stabbed herself in the leg to make her leg stop twitching. It worked. Of course, now her pain was “at least a twelve” on a 1-10 scale. And her allergy list included all NSAIDS, codeine, and Tramadol. She got cleansed, sewn up, and discharged with Tylenol – fortunately she wasn’t allergic to that. She also got to follow up with the neurologist to address the case of the incessantly twitching leg. The knife got confiscated and thrown into a sharps bin. And everyone kept wondering what she was going to do with her baloney after that incident … ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me. By the way, I’m making full blog posts available to the RSS readers and newsfeeds to make them easier for subscribers to read. Want to help support this blog? If you’re looking to purchase medical supplies online, Pharmapacks.com has Home Medical Supplies for Less. They accept PayPal payments and have free shipping on orders over $69. This blog gets a small percentage of each sale as a commission at no added cost to the customer.

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A Case That Really Bugged Me

By Birdstrike M.D. “Here I am Well, I guess it’s no surprise Up to my knees in water Up to my ears in dragonflies”  -Gov’t Mule  I open my car door to walk in to work. I’ve never heard crickets as loud as the ones this summer in Georgia. A wall of steam-heat blasts me simultaneously as a giant BZZZ! BZZZ! dive-bombs my ear. Man, it’s hot in Georgia. And the bugs! I think to myself. I walk slowly towards the ED doors, barely moving, but still breaking a sweat. I walk through the double doors now enveloped by my refrigerated workplace. I pick up my first patient, tagged non-urgent: “6-year-old girl. Legs paralyzed.” That’s weird, I think to myself. Paralyzed? Non-urgent? Not a trauma? I walk in the room and there is a 6-year-old girl, sitting on the stretcher smiling, unconcerned. Her dad looks only slightly more concerned. “I can’t move my legs,” says the girl. “I was fine this morning, then after lunch, my legs started getting weak.” “Has she had any other symptoms like fever, headache, or weakness in the arms? How about, double vision? Rash, trouble swallowing, abdominal pain?” I ask. “No,” she says, with the infectious smile of a 6-year-old, as her dad also shakes his head in agreement. “Was she exposed to any chemicals,” I ask her father, “any sprays, or pesticides?” “Nothing at all,” he answers, puzzled. “La belle indifference,” I think to myself. Maybe this is Conversion Disorder. I do a full exam. Everything is normal, except for the fact that her legs do seem weak: very weak in fact, almost flaccid. And her leg reflexes: almost non-existent. It’s not a complaint you see every day in children, especially ones without trauma or a spinal cord injury. I go back to the physician charting area. I discuss the case with a few of my partners. “Is she faking?” asks Dr. Bill, 15 years my senior. “It’s probably Factitious Disorder. Remember, this department’s exploding with sick people right now.” “I vote for Guillan-Barré,” says Dr. Susan. “I also saw a kid with a spontaneous intracranial hemorrhage of the cerebellum once from an arteriovenous malformation and it presented sort of like this, but more with ataxia than weakness. You need to do a CT, LP, labs, and turf to Peds.” “Is there any double vision, or extra-ocular muscle weakness? I saw one like this 6 months ago. It turned out to be Myasthenia Gravis,” says Dr. Jim, as he leans over with a pained look on his face, scratching his legs violently. “You got anything for mosquito bites on you? Hydrocortisone cream, anything? I’m dyin’ here from these bites.” Whatever this turns out to be, it isn’t going to be something you see every day in the Emergency Department. I click on “board exam questions” in the hard drive of my brain. Miller Fisher syndrome? Lambert Eaton myasthenic syndrome? Organophosphate poisoning? Botulism? Some weird electrolyte imbalance? Encephalitis? Some rare porphyria variant? I’m digging deep, grasping.  She may need labs, brain CT, and possibly a lumbar puncture just to start. I walk back into the room to start over. Something doesn’t feel right about this. I sit down to take the history again. “Doc, I wanna’ ask you something…” says the dad. “Just a minute, let me examine her again,” I say, concentrating. I examine her again from head to toe, this time with my best textbook Physical Diagnosis exam. Her arms seem a little weak now, too. Or am I imagining it? BEEP!BEEP!BEEP!BEEP!BEEP!BEEP! screams a monitor from outside the room. “Doc, one more thing…” ...

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What’s the Diagnosis #21?

A patient presented for evaluation of dyspnea. Her trouble breathing had been going on for a few days and kept getting worse. No coughing. No fevers. No other symptoms. No medical history. She smoked a couple packs of cigarettes per week. Her physical exam was entirely normal. Lungs were clear. Heart sounds normal. Labs (including CBC, CMP, d-dimer, and cardiac enzymes) and chest x-ray normal. EKG normal. Intermittently, her pulse oximeter readings would dip down into the low 80s. Then she’d ring the call bell, stating that she couldn’t catch her breath. When staff went in the room to check on her, the saturations would go back up to the mid to high 90s. We ordered an ABG on room air which was normal. Then we had her walk up and down the hallway with the pulse oximeter attached. Her saturation stayed above 95% the whole time. The patient was getting more anxious and showed us multiple pictures of the oximeter on her iPhone with readings as low as 82%. She even began crying when we talked about sending her home with some steroids and a metered dose inhaler. “I’m afraid I’m going to die,” she said. Anyone have a diagnosis yet?   Lots of good guesses. Rest of the story and diagnosis posted in the comments section. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat’.com, please e-mail me.

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Neuro Consult Needed

A patient in her early 20s with longstanding history of seizure like activity gets brought back to the emergency department via ambulance for another “seizure.” While her whole body is shaking in the ambulance, she has the wherewithal to reach in her pocket, pull up her dad’s number on her cell phone, dial, and tell him to meet her at the hospital. Then, during her post-ictal period, she begins talking “baby talk,” which is apparently “normal” for her “seizures” and which is only relieved with IV Ativan. Oral medications just don’t seem to work on her. I gave her an appointment with Dr. Grumpy next week. ————————————————— This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on DrWhitecoat.com, please e-mail me.

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