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Post a good case, dammit.
Started by RustedFox
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About once every five years I get the good chuckle of standing down a "code stroke" when the blown pupil is from someone touching their eye after removing their scopolamine patch.
Healthcare hero. 💪
Healthcare hero. 💪
Here's a good case we had recently.
EMS arrives with an 60 YOF from home with a week of progressively worsening confusion and sleepiness.
Husband states his wife was recently diagnosed with diabetes and is drinking tons of water to stay hydrated.
While at triage she's found to be completely unresponsive with normal vital signs and blood glucose level.
Patient is taken into the resuscitation room and shortly afterwards begins having tonic clonic seizures.
For all the new interns on here what's the next move in terms of immediate patient management?
EMS arrives with an 60 YOF from home with a week of progressively worsening confusion and sleepiness.
Husband states his wife was recently diagnosed with diabetes and is drinking tons of water to stay hydrated.
While at triage she's found to be completely unresponsive with normal vital signs and blood glucose level.
Patient is taken into the resuscitation room and shortly afterwards begins having tonic clonic seizures.
For all the new interns on here what's the next move in terms of immediate patient management?
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I won't spoil the answer for the interns, but I just wanted to say that I recently had a similar thing with a guy coming in for feeling vaguely unwell, similar home behavior, similarly became rapidly confused then seized. Happened about a month ago. Was a fun case.
Have seen it in infants whose parents are cutting the formula with water to make supplies last longer.
I had a similar case. Young lady (20s) brought in altered then seized, was at a casino.
She had been drinking a 12-pack of Diet Coke daily for...well, who knows how long.
Don't do that.
Oh interesting, I didn't realize diet coke would drive down your sodium like that.
Always fun to catch people faking having sickle cell. It always confuses the hell out of me how these patients can fool doctors for years despite seeing 50 different physicians within our medical system. I usually find 1-2 cases a year, and almost all of them are pretty similar to this case I had a few weeks ago.
41 yo AA F w/ a hx of bipolar d/o, T1DM and self-reported sickle cell disease presenting for "typical pain crisis". Doesn't know what kind of hgb she has (SS, SC, trait?), not on any home meds, has no hx of CVAs/avascular necrosis/CKD/acute chest syndrome. Doesn't have a hematologist.
Look through her records and she has been to our facility several times a month for 5 years. Hgb typically 9-10. No one has ever bothered to perform a hgb electrophoresis despite multiple admissions for sickle cell pain crisis.
I'm at a loss for how anyone gets fooled by these patients. I get taking patients at their word, but how the hell does a 40+ year old self-reported sickle cell patient who clearly looks very healthy (true SCD patients at this age frequently look like they are on death's door), doesn't take any hydroxyurea, has none of the typical sickle cell comorbidities, doesn't have a hematologist, and hgb levels are inconsistent with sickle cell somehow trick 50 different physicians?
I told her the most I would give her is an ibuprofen, as she was smiling and singing along to music she was listening to on her phone when I walked in. Told her that I found it pretty unlikely that she has HgbSS given her story and chart reviewing her. I told her I would be sending off an electrophoresis that would definitively tell us whether she has SCD. She decided to immediately take off. Of course it came back as stone-cold normal. Not even sickle cell trait.
41 yo AA F w/ a hx of bipolar d/o, T1DM and self-reported sickle cell disease presenting for "typical pain crisis". Doesn't know what kind of hgb she has (SS, SC, trait?), not on any home meds, has no hx of CVAs/avascular necrosis/CKD/acute chest syndrome. Doesn't have a hematologist.
Look through her records and she has been to our facility several times a month for 5 years. Hgb typically 9-10. No one has ever bothered to perform a hgb electrophoresis despite multiple admissions for sickle cell pain crisis.
I'm at a loss for how anyone gets fooled by these patients. I get taking patients at their word, but how the hell does a 40+ year old self-reported sickle cell patient who clearly looks very healthy (true SCD patients at this age frequently look like they are on death's door), doesn't take any hydroxyurea, has none of the typical sickle cell comorbidities, doesn't have a hematologist, and hgb levels are inconsistent with sickle cell somehow trick 50 different physicians?
I told her the most I would give her is an ibuprofen, as she was smiling and singing along to music she was listening to on her phone when I walked in. Told her that I found it pretty unlikely that she has HgbSS given her story and chart reviewing her. I told her I would be sending off an electrophoresis that would definitively tell us whether she has SCD. She decided to immediately take off. Of course it came back as stone-cold normal. Not even sickle cell trait.
I thought Diet Coke actually had some sodium in it…
We had the exact same thing happen in NY. Pt had gotten away with it for years.
Had a young pt who came in complaining of terrible total body dolor, was getting tons of narcs, was always tachy and looked like she was legit. Cant really fake tachycardia. Nothing coming up on labs, imaging, etc.
Chick had been cracking open crash carts and injecting epi.
Discharge to jail.
Also had a guy who went into vtach suddenly. Everyone went rushing in. Dude was furiously flogging the dolphin. Best rounds ever describing that scenario.
Chick had been cracking open crash carts and injecting epi.
Discharge to jail.
Also had a guy who went into vtach suddenly. Everyone went rushing in. Dude was furiously flogging the dolphin. Best rounds ever describing that scenario.
Excuse my sloppy case format:
32F, M4 medical student, CC "vaginal bleeding", post partem, uncomplicated c-section approx 10-14 days prior, has been doing well at home, some continued spotting and changes 2-3 pads per day and got up to nurse her infant this morning and noticed what she describes as a a gushing, moderate amount of sudden vaginal bleeding followed by near syncope. At the time of presentation she states the bleeding has definitely slowed down.
VS 105/90, 85, 16, 99%, 98.6F
PE:
ABD: c-section site looks to be in appropriate stage of healing, remaining belly exam benign, GU: Deferred for the moment while I get pelvic set up and it looks like they are ready for US, so will let her get the US first.
Labs: Chemistries WNL, H/H 21/7, remaining CBC WNL
US: R ovarian cyst, uterus with no RPOC, no pelvic free fluid, otherwise nothing acute.
My clinical impression is that the pt has symptomatic anemia, likely from post partum bleeding (quizzical that it's happening 2 weeks after c-section?) and regardless of what the pelvic exam shows, she needs to come in for monitoring, potential further imaging, probable blood transfusion and repeat H/H in the a.m. OB is located in their own hospital within our main campus but this results in a "transfer". I want to get things moving so I get on the phone with her OB who is one NASTY doc who tries to berate me about the need to bring her in and insists she's totally stable for d/c from our ED. I quickly snap at her to either come see the pt or accept the transfer to women's hospital and she backs down and accepts.
Pt is back from US and tells the nurse that she is bleeding again and is noted to be pale, tachycardic in the 120s and having moderately heavy vaginal bleeding. Nurse grabs me and I rush into the room to see the pt white as a ghost, tachycardic in the 120s with BP 80s SBP, blood all in the stretcher. Pressure has recycled now and her BP is in the 60s, I quickly bark for 2L NS wide open, an additional PIV, 2U emergency release O neg and 1g TXA. I lay her back and do a quick cursory pelvic which doesn't show much other than a lot of congealed blood in the vaginal vault with new blood, all of it looks venous.
After fluids, TXA and blood products, BP has improved to 105 SBP and HR 100. Bleeding has slowed. I call and update OB. She requests transfer immediately and she's transferred to Women's hospital in guarded condition.
Day 2:
I look at the notes and they monitored her overnight, discharged her. No further imaging or procedures.
Day 3:
She shows up back in our ED with an identical CC. This time her vitals are stable and she's not actively bleeding but had another "gush" of blood this a.m. followed by near syncope. One of my colleagues has her this time. H/H (post transfusion) is 7/22. He calls OB and the doc on call for her surgeon asks for CT prior to transfer. CT A/P w/contrast shows large R uterine pseudo aneurysm.
IR gets consulted, she gets admitted for embolization/coiling and does well.
I did a lit search on this and it's such a rare complication from c-section that there have only been 57 documented cases in the entirety of human medical literature.
Yes, I looked back at the original US from day 1 and there is no mention of any abnormal vascularity in the uterus. The R ovarian cyst is clearly described as ovarian. Either it was too small to see on that day, with rapid progression or it was not seen on US. Either way, it was a very interesting case.
32F, M4 medical student, CC "vaginal bleeding", post partem, uncomplicated c-section approx 10-14 days prior, has been doing well at home, some continued spotting and changes 2-3 pads per day and got up to nurse her infant this morning and noticed what she describes as a a gushing, moderate amount of sudden vaginal bleeding followed by near syncope. At the time of presentation she states the bleeding has definitely slowed down.
VS 105/90, 85, 16, 99%, 98.6F
PE:
ABD: c-section site looks to be in appropriate stage of healing, remaining belly exam benign, GU: Deferred for the moment while I get pelvic set up and it looks like they are ready for US, so will let her get the US first.
Labs: Chemistries WNL, H/H 21/7, remaining CBC WNL
US: R ovarian cyst, uterus with no RPOC, no pelvic free fluid, otherwise nothing acute.
My clinical impression is that the pt has symptomatic anemia, likely from post partum bleeding (quizzical that it's happening 2 weeks after c-section?) and regardless of what the pelvic exam shows, she needs to come in for monitoring, potential further imaging, probable blood transfusion and repeat H/H in the a.m. OB is located in their own hospital within our main campus but this results in a "transfer". I want to get things moving so I get on the phone with her OB who is one NASTY doc who tries to berate me about the need to bring her in and insists she's totally stable for d/c from our ED. I quickly snap at her to either come see the pt or accept the transfer to women's hospital and she backs down and accepts.
Pt is back from US and tells the nurse that she is bleeding again and is noted to be pale, tachycardic in the 120s and having moderately heavy vaginal bleeding. Nurse grabs me and I rush into the room to see the pt white as a ghost, tachycardic in the 120s with BP 80s SBP, blood all in the stretcher. Pressure has recycled now and her BP is in the 60s, I quickly bark for 2L NS wide open, an additional PIV, 2U emergency release O neg and 1g TXA. I lay her back and do a quick cursory pelvic which doesn't show much other than a lot of congealed blood in the vaginal vault with new blood, all of it looks venous.
After fluids, TXA and blood products, BP has improved to 105 SBP and HR 100. Bleeding has slowed. I call and update OB. She requests transfer immediately and she's transferred to Women's hospital in guarded condition.
Day 2:
I look at the notes and they monitored her overnight, discharged her. No further imaging or procedures.
Day 3:
She shows up back in our ED with an identical CC. This time her vitals are stable and she's not actively bleeding but had another "gush" of blood this a.m. followed by near syncope. One of my colleagues has her this time. H/H (post transfusion) is 7/22. He calls OB and the doc on call for her surgeon asks for CT prior to transfer. CT A/P w/contrast shows large R uterine pseudo aneurysm.
IR gets consulted, she gets admitted for embolization/coiling and does well.
I did a lit search on this and it's such a rare complication from c-section that there have only been 57 documented cases in the entirety of human medical literature.
Yes, I looked back at the original US from day 1 and there is no mention of any abnormal vascularity in the uterus. The R ovarian cyst is clearly described as ovarian. Either it was too small to see on that day, with rapid progression or it was not seen on US. Either way, it was a very interesting case.
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One of my wife's hospitalist partners had her c-section wound dehisce post-partum day 7 in the shower. Caught her own intestines before they hit the floor.
Now there’s a pretty damn impressive case. Good on you for advocating for your patient.
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Ok, so here’s my best case from recent memory. Sorry for crappy phone formatting.
55M signed out from prior doc. Here for hematemesis, history of EtOH cirrhosis, had an EGD with banding of some varices done at hospital in Venezuela a few days ago. Stable, BP 110s systolic, O2 98%, not tachy, alert, pending admission at signout, GI says obs, outpatient scope after discharge. Enjoying his protonix and octreotide drips, complaining about NPO status.
Triage labs:
Hemoglobin 10.6
INR 1.8
Scattered electrolyte, renal, and hepatic findings consistent with CLD, but none markedly concerning.
About 7 minutes into the shift I peek over my desk and the guy is now covered in black emesis, unresponsive, O2 low 80s, and agonal breathing. BP now 90/50 and tachy 110s. Stat RSI, airway full of blood but luckily goes smoothly.
Recycle the BP and now it’s 70/40, call for Massive Transfusion Protocol, the nurse drops an OG tube, and it immediately begins pouring out mixed black blood, clots, and gunk. The OG is putting out this black trash so fast it burns through both of our suction canisters in about 10 minutes. I send the MS4 off to find “as many suction canisters as you can carry.” We start the first 2 units of PRBCs via level 1 infuser. After the first 2 units the BP is now 65 systolic, blood still pouring from the NGT, so we call for FFP, platelets, calcium, TXA.
Now 4 units of blood, 1 platelet, 1 FFP in and I’m Hammer paging GI, who is kind enough to inform us in person the guy is now too sick to be scoped, should go to ICU, they’ll see him if he makes it up there.
Total NGT output is now 4L, BPs still in the 65-75 systolic range. We decide to go for our Hail Mary and drop a blakemore tube. By some miracle we’ve got the one nurse working who actually knows where all the components are. We attempt to pass the tube but the dude has some weird oropharynx anatomy and it just keeps curling in his throat. NGT output is now over 5L of blood.
Suddenly I have an amazing idea! Let’s pass the blakemore like an NG tube. We get it through the guy’s nose but it keeps curling in his mouth. So I shoved my whole hand in this dudes mouth while the MS4 held the ET in place, grabbed the blakemore, and manually passed it into the esophagus. We inflate the thing, tie it to the wall for tension, and within a couple of minutes the bloody output stops and BP starts to creep up into the 90s. Me and the attending, who has balls of steel for letting me try that, high five all around.
All in all the gentleman went to the MICU with a total blood loss of 6 L, received 11 units of products (6 PRBC, 4 FFP, 1 platelet). Lowest hemoglobin, drawn during the resus, was 2.8.
Scoped and banded in the MICU, woke up Neuro intact a few days Later.
55M signed out from prior doc. Here for hematemesis, history of EtOH cirrhosis, had an EGD with banding of some varices done at hospital in Venezuela a few days ago. Stable, BP 110s systolic, O2 98%, not tachy, alert, pending admission at signout, GI says obs, outpatient scope after discharge. Enjoying his protonix and octreotide drips, complaining about NPO status.
Triage labs:
Hemoglobin 10.6
INR 1.8
Scattered electrolyte, renal, and hepatic findings consistent with CLD, but none markedly concerning.
About 7 minutes into the shift I peek over my desk and the guy is now covered in black emesis, unresponsive, O2 low 80s, and agonal breathing. BP now 90/50 and tachy 110s. Stat RSI, airway full of blood but luckily goes smoothly.
Recycle the BP and now it’s 70/40, call for Massive Transfusion Protocol, the nurse drops an OG tube, and it immediately begins pouring out mixed black blood, clots, and gunk. The OG is putting out this black trash so fast it burns through both of our suction canisters in about 10 minutes. I send the MS4 off to find “as many suction canisters as you can carry.” We start the first 2 units of PRBCs via level 1 infuser. After the first 2 units the BP is now 65 systolic, blood still pouring from the NGT, so we call for FFP, platelets, calcium, TXA.
Now 4 units of blood, 1 platelet, 1 FFP in and I’m Hammer paging GI, who is kind enough to inform us in person the guy is now too sick to be scoped, should go to ICU, they’ll see him if he makes it up there.
Total NGT output is now 4L, BPs still in the 65-75 systolic range. We decide to go for our Hail Mary and drop a blakemore tube. By some miracle we’ve got the one nurse working who actually knows where all the components are. We attempt to pass the tube but the dude has some weird oropharynx anatomy and it just keeps curling in his throat. NGT output is now over 5L of blood.
Suddenly I have an amazing idea! Let’s pass the blakemore like an NG tube. We get it through the guy’s nose but it keeps curling in his mouth. So I shoved my whole hand in this dudes mouth while the MS4 held the ET in place, grabbed the blakemore, and manually passed it into the esophagus. We inflate the thing, tie it to the wall for tension, and within a couple of minutes the bloody output stops and BP starts to creep up into the 90s. Me and the attending, who has balls of steel for letting me try that, high five all around.
All in all the gentleman went to the MICU with a total blood loss of 6 L, received 11 units of products (6 PRBC, 4 FFP, 1 platelet). Lowest hemoglobin, drawn during the resus, was 2.8.
Scoped and banded in the MICU, woke up Neuro intact a few days Later.
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That lady is hard core. Held a towel over it, came out and calmly told her husband to call EMS then just sat and waited for them.
She may not be completely human...
Psst.
What's "MTP"?
This is one of those times where the answer is obvious to everyone but me.
I had a lady with gastro who kept injecting herself intravenously with bottle water to "stay hydrated." Sodium of 108.
I admired her tenacity.
Had 2 other kids and no immediate child care. EMS took her in while her husband found someone to watch the kids then followed to the hospital.
Also, doesn't EMS have morphine?
Probably Massive transfusion protocol
You seem weirdly anti-EMS, why is that?
No argument there, I just find it odd that you think a woman who was literally disemboweled should not have taken the ambulance to the emergency department.
Much like EMS throwing a tourniquet on everything they can just to be safe, I'd want her in an ambulance if it hit the fan.
There are many reasons not to use an ambulance. Hers is one I'd welcome on mine with open arms lol.
There are many reasons not to use an ambulance. Hers is one I'd welcome on mine with open arms lol.
Did you ever rIde the bus? When internal organs are external, that is not so blasé and could be construed as the definition of "severe distress". I mean, the flip side is the "severe distress", apparently, which turns out to just be someone histrionic and can't "adult" well, if at all.
And, do you know what would happen if you were in your POV, and a police officer stopped you for speeding, and you claimed a medical emergency? They're not going to let you go. They call EMS, and you +/- get a speeding ticket (since you weren't the pt).
Dude, you really questioning why someone that is disemboweled would call EMS? You serious?
I think he misread the original post. I did at first.
That's rather gracious of you, but, I don't really see how anything could be misconstrued.
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Guts hanging out? Yea, I'd call EMS for that.
MTP=Mass Transfusion Protocol
MTP=Mass Transfusion Protocol
The officer escorting you to the hospital in your POV is a Hollywood fallacy. The risk is way too high. Maybe you just have lived in a really permissive locale.
Ah the never ending battle with GI doctors who don’t seem to understand the concept of bleeding control. Nevertheless, great case.
Slightly different but I had a case recently of someone who came in as an AMS/resus with recently diagnosed diabetes outpatient by an NPP at a well known sketchy clinic.
28 years old, previously healthy, ex-military male fitness instructor in great shape. Sugar was 110s. Opening pH was 7.0, with a gap of 25, bicarb undetectable on our iStat.
They started her on an SGLT2 inhibitor (but no metformin?), did no other workup as to why this healthy person suddenly had DM, just assumed DM2. Turns out it was adult onset type 1, and sent the person into euglycemic DKA.
Bro her intestines are outside her body, wtf are you talking about? Yes you call EMS at that point…….
People are strange. Pt here fought his sister to drive himself to the ER after excising and peeling out his own gastrocnemius in a logging accident. Colleague said “looked like“ whole back of his leg was hanging off by the muscle’s insertion point. I got to see pics of the scar from the 2-year follow up with surgery.
DM1? Doesn’t have to be type 1 to go into DKA with SGL2 inhibitor.
How far are you in your training?
- Common diseases with common presentations are the easiest diagnoses to make.
- Common diseases with variable presentations are harder, but still easy, since we get a lot of practice with their variations.
- Uncommon diseases with common presentations are also easy, because they're interesting, easy to remember & we memorize them for exams.
- Uncommon diseases with variable presentations are the hardest to make.
We get little to no practice with them and they often present at odds with what we've memorized in books. That allows us to convince ourselves we're more likely looking something common, routine and benign. They can be sometimes be missed >50% of the time, even by experienced personnel. These are your "interesting cases."
Do you have kids? Lol.
this would have been a cool case. Long story short. Getting this antivenom is a pain in the ass. Only a couple places on the east coast have it. Escaped zebra cobra in Raleigh was captured with glue traps: What happens next?
Amp of HCO3!!
1 ampule (50 mL) of 8.4% NaHCO3 has ~equivalent toxicity to 50 mL of 6% Na or 100 mL of 3% Na (the standard correct answer), but is much more readily available.
I've never seen/heard of a patient surviving after a Blakemore. Crazy case.
Great save! Esophageal tamponade devices are tough to place. It may help to try slathering the distal portion of the tube in gel, and hooking a bougie into the distal port. This gives the tube a bit of rigidity to get through the initial portion of the esophagus. Using a laryngoscope for the initial stages of the insertion is also helpful.
I've never seen a Blakemore and all it's parts AND the obligatory Football helmet make it to the ED... much less make it into a patient for said patient to survive!
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The football helmet came late but did eventually arrive from sterile processing!
I was kinda bummed it didn’t have our institutions logo on it or something.
Attachments
Ok after talking with my wife I have to addend this story.
She drove herself to the ED, so she also didn't think EMS was needed.
Like the rural NC farmer guy with the manual transmission in his truck, who drove himself in with his bi- or tri-mal fracture of his left ankle.
Sometimes, folks don't make the best decisions. It's good fortune that there is not a worse outcome.
D
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Curiosity question from the peanut gallery --
As a few previous posters have alluded to, Diet Coke has a little bit of sodium (40 mg/12 fl oz serving). Was the fact that it was diet pop specifically a red herring in this case and it was simply the volume of water? (12 pack of 12-oz cans = 144 oz = 4.26 L of fluid a day!) Diet pop doesn't have much caffeine in it compared to coffee (46 mg/12 oz Diet Coke vs 136 mg/12 oz coffee) - perhaps she was drinking a large volume of it for the caffeine content?
Good question.
I figure that I drink about a 12-pack of seltzer water a day. Maybe that's a bit much, but I easily go thru 8-10 cans.
