- Joined
- Dec 19, 2010
- Messages
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"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
Well, I guess it's no surprise
Up to my knees in water
Up to my ears in dragonflies" -Gov't Mule
Let me tell you about a case that really bugged me...
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, its 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." Thats 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. Its probably Factitious Disorder. Remember, this departments 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 isnt 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? Im 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.....(read more)
