What could this have been? Answers elude me...

[vernhart]

---

Members don't see this ad.

Will try to keep this as brief as possible. Want to clarify before, that I am not asking for diagnoses/medical advice as the patient (my dad) has already been treated. Just puzzled and wanting answers.

We are all having a family cookout and decide to have a water gun fight. My dad at one point runs away toward the driveway, but trips over the bushes (wasn't looking where he was running). His head (pterion area) hits the concrete driveway. He sits up, and immediately a transparent amber colored fluid drips quickly from one nostril before slowing and eventually stopping (total of five seconds max that it leaked from his nose). Not having any idea what it was, we go to the ER. I try to explain the fluid...and why the heck we are at the ER when he didn't lose consciousness and had no change in mental status... to them (for obvious reasons he couldn't see it as well as I could) by telling them it looked to me like the CSF mixed with blood I had seen in the spinal dura when dissecting my cadaver (best comparison I could think of at the time...). The PA immediately scoffed, laughed, and without explanation said "no" and was just going to leave when I asked what it could be. Her answer...nasal drainage? I'm no doctor yet...but I HAVE had plenty of nasal drainage. It looks nothing like this stuff. Maybe she's right, but no reason to act like we were dumb for being worried and thinking it could have been something far more serious. Aside from the point, though... anyone have any insight as to what this could have been?

He's fine. They did a CT and such btw. Just curious bc I can't find any answers online.

TLDR: amber colored substance drips from nose after head trauma...what could it be?

Don't forget to poll in for the bonus question

 

[bannie22]

Does it drip drip drip

Should hve just sent it for beta2transferrin if u were so academically inclined.

Also cud have consult ent for scope.

Cisternogram
Pledget study etc
Drop a ld

 

[ALLMIGHT_SMASH]

That stinks that the PA scoffed and laughed. I mean even if it was no big deal they shouldn't have been a jerk about it. Hell, they could have even made it more of a learning opportunity for you... What probably should have been said. "Hmm, well the reason I don't believe it is CSF is because abc but if you are really worried about it we can make sure by doing xyz"

 

[vernhart]

That stinks that the PA scoffed and laughed. I mean even if it was no big deal they shouldn't have been a jerk about it. Hell, they could have even made it more of a learning opportunity for you... What probably should have been said. "Hmm, well the reason I don't believe it is CSF is because abc but if you are really worried about it we can make sure by doing xyz"

yeah, they knew I was a medical student so you would think...

 

[vernhart]

Does it drip drip drip

Should hve just sent it for beta2transferrin if u were so academically inclined.

Also cud have consult ent for scope.

Cisternogram
Pledget study etc
Drop a ld

if only I had saved it in a vial! haha yeah it dripped quickly (before slowing), not in a constant stream

 

[fahimaz7]

Basilar skull fractures are rare. In the last 5 years I've only seen a few and they were either altered or intubated with good mechanisms of injury. CT is a good test for if read by a neuroradiologist. Common things happen commonly and odds are that he doesn't have a csf leak that resolved after 5 drops.

Med students are trained to think of all the possibilities without an appreciation of the prevalence of said processes.

 

[iBS1972]

Interested in the answer to this as well. From description, it does sound like CSF leak.
One thing's for certain though, the PA responded in a very unprofessional manner to her patients (yes, care-takers of patients should be treated with the same level of respect and understanding as the actual patient).

 

[iBS1972]

Basilar skull fractures are rare. In the last 5 years I've only seen a few and they were either altered or intubated with good mechanisms of injury. CT is a good test for if read by a neuroradiologist. Common things happen commonly and odds are that he doesn't have a csf leak that resolved after 5 drops.

Med students are trained to think of all the possibilities without an appreciation of the prevalence of said processes.

While I agree with everything you've said, I would assert that statistics can only be generalized to the population. It doesn't matter if it's 1 in a million or 1 in a billion, if the patient has it then the patient has it. Not saying that he necessarily has CSF leak, just saying that prevalence/incidence data is not sufficient to not give a diagnosis the respect it deserves. OP was merely applying his knowledge, absolutely nothing wrong with that. Even if he were wrong and the diagnosis is extremely unlikely, it does not justify demeaning behavior by the medical professionals.

Just curious, what would your differential be? (i guess besides very dilute epistaxis?)

Edit: I'm guessing that you're an attending, and everything I say you already know. Just wanted to clarify that I mean no disrespect.

 

[vernhart]

Basilar skull fractures are rare. In the last 5 years I've only seen a few and they were either altered or intubated with good mechanisms of injury. CT is a good test for if read by a neuroradiologist. Common things happen commonly and odds are that he doesn't have a csf leak that resolved after 5 drops.

Med students are trained to think of all the possibilities without an appreciation of the prevalence of said processes.

much more than five drops (dripping stopped after five seconds)...just wanted to clarify (not that it probably changes the conclusion you reached)

 

[fahimaz7]

While I agree with everything you've said, I would assert that statistics can only be generalized to the population. It doesn't matter if it's 1 in a million or 1 in a billion, if the patient has it then the patient has it. Not saying that he necessarily has CSF leak, just saying that prevalence/incidence data is not sufficient to not give a diagnosis the respect it deserves. OP was merely applying his knowledge, absolutely nothing wrong with that. Even if he were wrong and the diagnosis is extremely unlikely, it does not justify demeaning behavior by the medical professionals.

Just curious, what would your differential be? (i guess besides very dilute epistaxis?)

Edit: I'm guessing that you're an attending, and everything I say you already know. Just wanted to clarify that I mean no disrespect.

I see patients on a daily basis during our busy season (ski season) who claim to have rhinorrhea after hitting their head. I have yet to find one in an awake, normal appearing patient in my emergency department after looking for it on many occasions. GCS= 15, A&Ox4, no CN deficits, CT negative, symptoms stopped, and no objective data to support the diagnosis makes it much less likely. My guess is that the OP tried to insert himself into the workup and the PA decided to shut him down and reassure the patient. While we should think of zebras in medicine, we need to appreciate the fact that most of us live in America and a zebra is a rare breed indeed.

With that said, I recently had an unresponsive 23 y/o male with a BUN:CR of 260:33, uremic pericarditis, and cardiac tamponade physiology (no known medical problems). That was my rare zebra of the year.

 

[ERDOC555]

Will try to keep this as brief as possible. Want to clarify before, that I am not asking for diagnoses/medical advice as the patient (my dad) has already been treated. Just puzzled and wanting answers.

We are all having a family cookout and decide to have a water gun fight. My dad at one point runs away toward the driveway, but trips over the bushes (wasn't looking where he was running). His head (pterion area) hits the concrete driveway. He sits up, and immediately a transparent amber colored fluid drips quickly from one nostril before slowing and eventually stopping (total of five seconds max that it leaked from his nose). Not having any idea what it was, we go to the ER. I try to explain the fluid...and why the heck we are at the ER when he didn't lose consciousness and had no change in mental status... to them (for obvious reasons he couldn't see it as well as I could) by telling them it looked to me like the CSF mixed with blood I had seen in the spinal dura when dissecting my cadaver (best comparison I could think of at the time...). The PA immediately scoffed, laughed, and without explanation said "no" and was just going to leave when I asked what it could be. Her answer...nasal drainage? I'm no doctor yet...but I HAVE had plenty of nasal drainage. It looks nothing like this stuff. Maybe she's right, but no reason to act like we were dumb for being worried and thinking it could have been something far more serious. Aside from the point, though... anyone have any insight as to what this could have been?

He's fine. They did a CT and such btw. Just curious bc I can't find any answers online.

TLDR: amber colored substance drips from nose after head trauma...what could it be?

Don't forget to poll in for the bonus question

Theoretically, could it have been CSF from a fractured cribriform plate? or would the dura mater protect this area even with a fracture?

Now you have me curious as to mechanisms by which CSF could come through the nose

 

[Gorne]

When the PA scoffed at you after a legitimate concern that at least deserved an answer, (Fluid draining out of body orifices after trauma isn't something to scoff at) you should have demanded to speak with someone who didn't earn their degree online.

 

[watermelon master]

When the PA scoffed at you after a legitimate concern that at least deserved an answer, (Fluid draining out of body orifices after trauma isn't something to scoff at) you should have demanded to speak with someone who didn't earn their degree online.

I don't think PA schools are online? Maybe 1 exception or something?

 

[Gorne]

I don't think PA schools are online? Maybe 1 exception or something?

When insulting people it's not so much about the accuracy, it's more so about the savagery.

 

[vernhart]

Theoretically, could it have been CSF from a fractured cribriform plate? or would the dura mater protect this area even with a fracture?

Now you have me curious as to mechanisms by which CSF could come through the nose

it would have to tear the dura also for CSF to leak into the sinuses; that's where my head was at though (despite the location of impact making this unlikely, the fluid had me worried)

 

[vernhart]

I see patients on a daily basis during our busy season (ski season) who claim to have rhinorrhea after hitting their head. I have yet to find one in an awake, normal appearing patient in my emergency department after looking for it on many occasions. GCS= 15, A&Ox4, no CN deficits, CT negative, symptoms stopped, and no objective data to support the diagnosis makes it much less likely. My guess is that the OP tried to insert himself into the workup and the PA decided to shut him down and reassure the patient. While we should think of zebras in medicine, we need to appreciate the fact that most of us live in America and a zebra is a rare breed indeed.

With that said, I recently had an unresponsive 23 y/o male with a BUN:CR of 260:33, uremic pericarditis, and cardiac tamponade physiology (no known medical problems). That was my rare zebra of the year.

I was actually quiet in the corner until asked about what I saw, but sure...go ahead and assume I was the problem. Funny enough, a**h***s aren't zebras among care providers despite your clear bias. I mean, reassure the patient by abruptly exiting? Look, I get that you can't trust that I'm a reliable narrator, but I don't think it's cool to assume I was trying to interfere with them doing their jobs and they did nothing wrong bc you weren't there. The real point of the thread was the identity of the fluid...not whether I was right to guess that or right in the situation (the poll is a joke...I was there and I know mistreatment when I see it and don't need others to validate it), but I couldn't help but entertain your second reply with a response bc I don't think this guess of yours was fair

 

[watermelon master]

BBQ/ketchup tinged saliva from his throat getting launched up into his nose from the fall?

 

[deleted862527]

That was rude of the P.A. to respond like that.

But when you become a Doctor, you'll get your revenge once you become her boss. 🙂

 

[ACSurgeon]

That was rude of the P.A. to respond like that.

But when you become a Doctor, you'll get your revenge once you become her boss. 🙂

You're in for a rude awakening when you finish training... Doctors are hardly anyone's boss anymore. If anything we are scrutinized and end up having to tolerate the bad behavior of the ancillary staff. Welcome to 2017.

 

[deleted862527]

You're in for a rude awakening when you finish training... Doctors are hardly anyone's boss anymore. If anything we are scrutinized and end up having to tolerate the bad behavior of the ancillary staff. Welcome to 2017.

With this said, is it still worth it to become a Doctor? A lot of people always list the cons of becoming a Physician. I personally can't see myself doing anything else. I know there is intense commitment, but do you at least have some time for yourself? Or are you 24/7 dedicated?

 

[Vrachika]

I would have immediately thought that it was spinal fluid...head trauma + clear liquid (possibly mixed with blood) coming out of nose, ears, etc.

I was a lifeguard and I actually taught lifeguards, CPR, first aid etc, and that sounds like a textbook spinal injury...but if your dad had imaging done then I guess he's alright. I hope they at least included the top third of the spinal column in those images.

But I don't know anything, I'm just a premed 😛

Either way you guys were definitely right to take him in to get checked out!! That was rude of the PA to act that way.

 

[ACSurgeon]

With this said, is it still worth it to become a Doctor? A lot of people always list the cons of becoming a Physician. I personally can't see myself doing anything else. I know there is intense commitment, but do you at least have some time for yourself? Or are you 24/7 dedicated?

I think the medicine is amazing. The politics not so much. There's a lot of playing the game rather than setting the rules. Not the good old days for sure. Some good and some bad comes with that.

And no, definitely not 24-7 committed now that training is over. My family time is protected.