Sunday, April 11, 2010

Difficult Case

Okay, all you armchair neurologists, I'm on call this weekend, and it's time for you to help me with DR. GRUMPY'S CHALLENGING PATIENT.

Here's the story:

Mrs. Smith was mugged outside Local Mall yesterday, in an event witnessed by several bystanders. Mr. Scumbag hit her over the head with a crowbar (she'll be fine, don't worry) knocking her out, and grabbing her purse (he's already been caught).

So she was admitted to Grumpy Hospital. And the admitting internist wrote in the chart:

"Neurology consult with Dr. Grumpy, to determine why patient lost conciousness."

This one has me stumped, so if any of you want to chip in ideas to help, I'd appreciate it.

56 comments:

Nuclear Fire said...

I'd consider an underlying movement disorder. Why else would she not have moved out of the way of the crowbar?

Anonymous said...

Actually Dr G, I do believe the admitting internist, needs the consult..If someone is hit on the head with a crowbar..chances are they would loose conciousness. Now, can you help Dr Internist??

mm

redgirl said...

I'm thinking that Local Mall was under terrorist bio-gas attack. She *obviously* passed out from the fumes.

Tassiegal said...

Well seeing I havent taken my sarcasm today it would be...your loss of conciousness due to inability to apply logic to said situation....

In notes I would probably write - re LoC see police report.

Anonymous said...

or better yet, Dr Internist needs to see a proctologist, to GET HIS HEAD OUT OF HIS ASS!!!!!!!!

how do you put up with these crazy ass, people????????

MM

Anonymous said...

That's a hard one, Doctor Grumpy. Is there anything in the patient history that could explain it?
Here, this is for you: a ship missing for 200 years has resurfaced.
http://ca.news.yahoo.com/s/capress/100410/world/us_warship_resurfaces

Suburban Princess said...

I think we need to know what was in her purse before we make any guesses!

terri c said...

Patient lost consciousness initially pursuant to being struck with the crowbar. She regained consciousness in the field but lost consciousness upon arrival in the ED when, after 5 seconds in his presence, she realized Dr. Internist's complete lack of critical thinking skills.

Anthony said...

Just asking, would "what the hell do you think?" fly as an answer?

Stitch's boo said...

Heavy metal poisoning?

Amy said...

Wow, that is a challenge! LOC can be a challenge to diagnose unless there is an obvious exogenous cause like getting hit in the head with a crowbar.

Julie said...

mmm, tough one ... definitely needs a specialist consult

Dymphna said...

Define "she's fine".

Hit over head with crowbar -> lost consciousness -> fine? How does that work?

Does she have a follow up appointment to insure that today's definition of "fine" remains true?

What is the expiration date on TBI presentations again?

Nuclear Fire said...

So, how long of a note did you write? Did you passively-aggressively mock the internist with a long differential or do a 4 line SOAP note instead?

Cthulhu Sashimi said...

Just prior to the mugging, Mr. Scumbag had gone to the mall's head shop and bought several vials of Rush, which he'd then consumed in the mistaken belief that they were energy drinks. While in the process of hitting Mrs. Smith over the head with a crowbar, he breathed in her face.

Dana RN said...

Bad Timing Disorder?

Kat's Kats said...

Internist put the consult request on the wrong patient chart?

Anonymous said...

This may be a reaction to the internist being previously fussed at by a specialist. "How dare you put a conclusion in the notes that only a specialist like me can determine".
Internist then gets childish and writes the note indicated. I wonder how many other silly notes this doctor has written?

Anonymous said...

She lost consciousness due to a sudden drop in blood pressure. Mr. Scumbag happened to be nearby when this occurred, and he happened to still be carrying the crowbar he'd just used to extricate a couple of children who'd gotten trapped in the Dance Dance Revolution machine at the arcade. Thinking fast, he swung the crowbar at her head, in the hopes that he could startle her and the sudden rush of adrenalin would revive her. When this didn't work, he grabbed her purse so he could look inside and find her name and relevant medical information in order to help the paramedics. And that's when this Good Samaritan was unjustly arrested and faces the loss of his reputation and the ruination of the charity projects to which he's devoted his life. And all to help some woman who'd just been caught trying to shoplift a copy of "Mein Kampf" from Waldenbooks.

Anonymous said...

The whole getting-hit-in-the-head-with-a-crowbar thing was so cliched that it brought about a serious case of existential ennui.

Anonymous said...

She'd just returned from a trip to India and was suffering from a bad case of jet lag. The rest was just coincidence.

Filet-o-bitch RPh said...

The pharmacist gave her ampicillin instead of amoxicillin?
she overdosed on her hubbys viagra?
She took too many oxy's?

Phil said...

To be fair, Admitting Internist was probably on day #5 straight in a row, exhausted and sleep-deprived at 3AM, and cursing his miserable existence -- not really giving a crap about whether or not Smartass Neurologist would see his writing, find it amusing, and post it on the internet for all to see.

08armydoc said...

Dr Grumpy - Try this as an experiment to help with the answer: hit Dr. Internist in head w crowbar; if he loses consciousness, that may be the answer. If he does NOT lose consciousness, I'd suggest hitting him in the head repeatedly to verify that it's NOT the answer. If he still remains conscious, he needs a neurology consult.

Anonymous said...

remember, you are better at reading the ct than either the internist or the radiologist.

Anonymous said...

She was trying to quit smoking and was being treated by a hypnotherapist. "When I swing this crowbar, you will become very, very sleepy."

Lovin Life! said...

hmmmm...this one's a stumper. Did you check her fluid status? Maybe a-fib? I dunno. I'm stumped as well.

ER's Mom said...

I have to say, if even a dumb OB like me can make a very good guess as to the cause of LOC, why can't the thinking doctor?

Carol S. said...

Common sense is not common, especially with highly educated people (sorry Grumpy).

John Woolman said...

Was it really an internist and not an orthopod?

RehabNurse said...

Grumpy:

Said crowbar wielder nursing diagnosis:

Ineffective coping d/t crowbar wielding r/t economic disparity (lack of funds)

Purse lady:

Trauma d/t crowbar r/t economic items located in personal effects (purse)

Internist:

Ineffective coping r/t lack of coffee (and/or approved beverage) d/t extended hours on weekend when he/she could have been 1)participating in economic activities (shopping) or 2)watching Tiger Woods return to golf

Just my 2 cents...and some nursing diagnoses...don't look for them in your electronic health record or ICD-9.

Anonymous said...

Must have been arrhythmic! CardioNP

danielle said...

Blame it on an earthquake - which caused uncontrollable movement - ending up in the patient bumping her own head against the crowbar the scumbag had just bought - which resulted in dropping her purse - which the scumbag was holding onto so that both of them could survive on the linty mints in the purse and the 1/2 bottle of water in case the mall collapsed....in other words, he was framed copper!

Katie said...

Maybe as part of his consult Dr. Grumpy should hit Dr. Internist on the head with a crowbar.

Anonymous said...

the orthopod assumes all loss of consciousness is caused by crowbars.

Memune said...

she tried to move away too quickly and suffered orthostatic hypotension? She has Ondine's Curse? She has a metal plate in her head ad the crowbar somehow, Idunno, magnetized it and zapped her brain?

Can't wait to see the follow up posts on this one!

Anonymous said...

Hyperkalemic Periodic Paralysis (late onset presentation)

A Doc 2 Be said...

I think Phil is the internist :D

hahaha.... sarcasma has not taken affect yet.

Wondering if it would be more effective to have a colonoscopy for the patient now as surely, the internist's head has been lost somewhere dark and stinky.

Dr. Astute said...

Unspecified diagnosis.

tottergirl said...

I've no idea. I also lose consciousness every time I'm whacked in the head with a crowbar too. Weird, huh?

Anonymous said...

Her cell phone was set on "stun."

Anonymous said...

It might have been the chloral hydrate that the internist treated her with.

Rosie said...

I'd consult the literature on this one...

GB, RN said...

Hah! Amateurs! We see this all the time.

The woman had her stash of coupons, one in particular was 50% off canned cat food, tucked safely away in her purse. The shock of having someone take her purse with her treasure inside, was too much for her to bear, so she passed out in an effort to protect her mind from the horror. Look into it further, you will probably find it was double coupon day, which makes the tragedy all the more heinous.

I'll be sending you my bill.

Anonymous said...

loc nos

j said...

Loss of consciousness from damaging someone's crowbar with her head.

Joe said...

Was she post ictal? Does she have a cardiac history? What were the physical exam findings?

I'd be concerned that she had a seizure or possibly a syncopal episode at the exact moment the crowbar struck her skull.

You should probably consult cards to go with the neuro consult just to cover all the bases.

Anonymous said...

So was she charged for a consult because of the idiot who asked for it?

missaunt said...

Bless Dr. Intern's heart. He must have slept late on the day of the TBI neuro lecture. I concur on the suggestion of an empirical case study with Dr. Intern being the case. I hope you didn't have to go in just for this one.

Phil said...

@A Doc 2 Be said...
> I think Phil is the internist :D

Thankfully, I'm not going into internal medicine. I just get the feeling that a large chunk of Doc Grumpy's readers aren't familiar with the concept of (1) the lucid interval during the night when reason and logic cease to exist, and (2) crappy attendings who like to pan-consult regardless of what time it is.

I'm a resident, and in my limited experience I've seen enough of both to be able to guess that this is one or the other. I understand this is how Doc Grumpy likes to vent, and my initial reaction is to laugh, too, but the peanut gallery in the comments seems to consist of a few knowing smirks scattered in between jeers from people who haven't a bloody clue what is going on. Sure is a tough place with tough guys, these Internets.

mommy-medic said...

That has GOT TO BE the SAME doc that asked if the patient- who was shot in the head- had a history of seizures! I don't know. I couldn't ask her. SHE'S SHOT IN THE HEAD!

KateA said...

Eh, no doubt he worded something wrong. He obviously knows that the crow bar caused her to lose consciousness, he just wants to find out if there are underlying problems that will surface later. But it does make for good blog fodder.

Anonymous said...

And here I thought being a doctor was hard. I could have TOTALLY been a doctor. Between the internist and Dr. Astute, I know I could have done it.

ERP said...

Hey, as they say, it's a "feed the bulldog" consult for ya. Piece of cake and you get enough money to feed that hungry guy.

Anonymous said...

I think if I were to be hit with a crowbar I would just faint.

Just Me said...

Phil
Yes, the internet can be a harsh world sometimes. But has it occurred to you that perhaps MOST of the people reading this and leaving comments actually DO know what it's like to go non-stop for many hours too long? Why is it that only Dr. Grumpy is the one with a pass on venting? Why do you think we read this? Some of us like knowing that others have it rough too. So, yeah, the internet is a tough place. So is life. Let us vent vicariously.

As for the above comments, I applaud everyone's creativity. However, the cat food coupons on double coupon day is CLEARLY reality. I, too, have seen a similar incident and can verify its accuracy.

 
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