A sad commentary from a nurse's assessment of a patient in her 60s who is 5'6" and weighs over 400 lbs:
"Patient presents with a pannus that extends past her knees when standing." ("Pannus," for the uninitiated, refers to a roll of fat that hangs down from the abdomen over the lap. It comes from the Latin word for "apron," which is appropriate, though more than slightly disgusting.) "Patient is morbidly obese to the point that she cannot provide basic hygiene beyond washing her face. A strong foul odor fills her room and the surrounding hallway."
The strong foul odor comes from the flesh under her pannus, which is essentially rotting due to being constantly moist and dirty.
This is an example of the unfortunate effect of having easy access to a lot of cheap food that is bad for you. Everywhere else in the world, the poor are thin because they have no food. Here in the US, the poor are fat. And, the concomitant health problems that stem from the obesity epidemic are having and will continue to have serious effects on the cost of health care.
The CDC reports, to nobody's surprise, that the average BMI in the US has increased since 1960 for both men and women from 25 to 28 (click here for the report).
With that appetizing image in mind, Merry Christmas! See you at the salad bar...
20091216
20091128
Red Ryder
This young man didn't listen when his mother warned him what would happen if he got that BB gun - that he would shoot his eye out.
Fortunately, his vision is still intact, and it doesn't look like his eyeball was penetrated. He does have some retinal hemorrhage, which will hopefully resolve.
20091127
Family togetherness at Thanksgiving
"Patient presents to the Emergency Department with mouth pain after an argument with his sister during which she hit him in the mouth with a bottle. His right three front teeth are chipped. The patient is tearful, but more upset about his appearance than the pain. He admits to drinking alcohol tonight."
20091126
Don Juan
"27-year old patient jumped from a window onto a balcony below when he heard his girlfriend's dad's voice coming to the bedroom." Don Juan here barely even qualifies as young - though his girlfriend still lives at home, so she may be. He broke his ankle very badly on that jump, which is no less than he deserves, the cad. The ten shots of vodka he drank doubtlessly affected his balance.
20091123
Unbelievable...
This is another history from my favorite type of patient:
"Patient in his 40's who 'accidentally' ingested Drano that he thought was alcohol."
And another:
"Woman with psychiatric history was visiting her boyfriend in the ER when she became aggressive and loud, yelling at the nurses, and was placed on a 5150 hold by the Sacramento Police Department."
For the uninitiated, a 5150 hold refers to the section of the California Welfare and Institutions Code that allows a policeman or clinician to place a person under involuntary confinement for up to 72 hours. The person has to be a danger to him or her self, and/or others and/or gravely disabled.
Her boyfriend was a patient in the ER as well, by the way. I am not sure what his issue is. He is probably not the guy who drank the Drano, though.
"Patient in his 40's who 'accidentally' ingested Drano that he thought was alcohol."
And another:
"Woman with psychiatric history was visiting her boyfriend in the ER when she became aggressive and loud, yelling at the nurses, and was placed on a 5150 hold by the Sacramento Police Department."
For the uninitiated, a 5150 hold refers to the section of the California Welfare and Institutions Code that allows a policeman or clinician to place a person under involuntary confinement for up to 72 hours. The person has to be a danger to him or her self, and/or others and/or gravely disabled.
Her boyfriend was a patient in the ER as well, by the way. I am not sure what his issue is. He is probably not the guy who drank the Drano, though.
20091122
20091031
Season's Greetings
This is the position in which this poor patient's hands are fixed, which is what happens when rheumatoid arthritis is poorly controlled.
20091005
20091004
Car vs. house
This is what can happen when the car you are joyriding in runs into a house while you are running from the police.
One of these hips is not like the other. The head of the patient's right femur (the one on the left of the image) is inside the pelvis, which is, as you might imagine, a suboptimal location for the femur.
It turned out that the patient was bleeding extensively from the left side of his pelvis, and needed the arteries that were bleeding blocked off. This was done by feeding a small tube through an artery in the right groin, putting the tube into the artery that was bleeding, then putting metal coils and small fragments of material that encourages clotting into the artery.
One of these hips is not like the other. The head of the patient's right femur (the one on the left of the image) is inside the pelvis, which is, as you might imagine, a suboptimal location for the femur.
It turned out that the patient was bleeding extensively from the left side of his pelvis, and needed the arteries that were bleeding blocked off. This was done by feeding a small tube through an artery in the right groin, putting the tube into the artery that was bleeding, then putting metal coils and small fragments of material that encourages clotting into the artery.
20091003
Two thumbs up
Self-explanatory title for this post.
One of the many weird skeletal malformations that can occur.
One of the many weird skeletal malformations that can occur.
20090830
Subtle Finding
This is something subtle I saw the other day:
Now - the question is this: does this patient have arthritis? Those joint spaces look a little narrow.
Har! I kid. Who cares about the joint spaces - what the heck is that thing on the patient's thumb?!
Answer: This is a squamous cell tumor. The patient initially noticed a small spot on her thumb several years ago, and went to a doctor. The doctor cut off the lesion and pronounced the patient cured. Unfortunately, the lesion slowly grew back over three years or so, and the patient did nothing about it, even though it was so huge, ulcerated and disgusting that she was unable to use her left hand. The thing also wept fluid; she had to keep it covered so it wouldn't stain her clothes, tablecloth, furniture, etc.
Ultimately she had the thumb amputated. They are looking at using one of her toes to give her a replacement thumb, since having an opposable digit is such a nice feature of the human hand. I am excited to see the radiographs of that. If I see those images, rest assured that they will show up here, as well.
In the meantime, remember that you need to follow up on things. If you have something cut off your skin and it just doesn't look right afterward - for example, if it grows to the size and shape of a potato - get it checked out.
Now - the question is this: does this patient have arthritis? Those joint spaces look a little narrow.
Har! I kid. Who cares about the joint spaces - what the heck is that thing on the patient's thumb?!
Answer: This is a squamous cell tumor. The patient initially noticed a small spot on her thumb several years ago, and went to a doctor. The doctor cut off the lesion and pronounced the patient cured. Unfortunately, the lesion slowly grew back over three years or so, and the patient did nothing about it, even though it was so huge, ulcerated and disgusting that she was unable to use her left hand. The thing also wept fluid; she had to keep it covered so it wouldn't stain her clothes, tablecloth, furniture, etc.
Ultimately she had the thumb amputated. They are looking at using one of her toes to give her a replacement thumb, since having an opposable digit is such a nice feature of the human hand. I am excited to see the radiographs of that. If I see those images, rest assured that they will show up here, as well.
In the meantime, remember that you need to follow up on things. If you have something cut off your skin and it just doesn't look right afterward - for example, if it grows to the size and shape of a potato - get it checked out.
20090222
Recurring theme
In keeping with the recent theme of this blog, here is another case I saw today.
A 44-year old man who had been in a motor vehicle accident in which he suffered severe brain damage - with consequent developmental delay - came in after being "found down" in the street. The medical record provides an understated description of what I am sure was an impressively squalid appearance:
"A 44-year-old gentleman who came in after being found on the street... Patient fidgety and agitated... [patient] states he was trying to get home and 'decided to crawl'... Patient stated he wanted the police to give him a ride home. He was somewhat confused and disheveled... Drinks alcohol on occasion. Has a history of IV drug abuse... In general, he is a somewhat disheveled gentleman covered with dirt [who is] not wearing any socks or shirt on a rainy day."
He complained of pain that worsened when he stood up. Urine testing showed that he had a raging urinary tract infection.
We got X-rays of his pelvis, which showed the following from the front:
from the side with the patient on his side:
and from the side with the patient on his back:
There are a few interesting things to note from this exam:
1. 4 round bright white things in the middle of the pelvis on the frontal view that change position on the view with the patient on his side and move to the back of the pelvis in the side view taken with the patient on his back. This suggests that those 4 round things are inside the bladder, and are rolling to whatever part of the bladder is closest to the center of the earth.
2. A large gray round thing in the pelvis that probably represents a large fluid-filled bladder.
3. Multiple round bright white things that project in the place where we would expect to find the urethra.
4. Plates and screws in the bones of the pelvis - mementos of the patient's previous auto accident.
Seeing all these things, I let the ER know that this guy had metallic foreign bodies in his urethra that are obstructing his bladder. Some of the metallic foreign bodies are actually inside his bladder.
On further questioning, it turns out that this guy had, for reasons that are unclear, put magnets up his urethra.
I guess he was bored, and didn't have a pencil.
Urology was called, and they tried to remove the metallic foreign bodies in the ER, though according to the medical record, they "[had] some difficulty." They took the patient to the operating room for definitive treatment with an endoscope.
And, for the record, this is the same guy who dropped all the eggnog in my last post.
A 44-year old man who had been in a motor vehicle accident in which he suffered severe brain damage - with consequent developmental delay - came in after being "found down" in the street. The medical record provides an understated description of what I am sure was an impressively squalid appearance:
"A 44-year-old gentleman who came in after being found on the street... Patient fidgety and agitated... [patient] states he was trying to get home and 'decided to crawl'... Patient stated he wanted the police to give him a ride home. He was somewhat confused and disheveled... Drinks alcohol on occasion. Has a history of IV drug abuse... In general, he is a somewhat disheveled gentleman covered with dirt [who is] not wearing any socks or shirt on a rainy day."
He complained of pain that worsened when he stood up. Urine testing showed that he had a raging urinary tract infection.
We got X-rays of his pelvis, which showed the following from the front:
from the side with the patient on his side:
and from the side with the patient on his back:
There are a few interesting things to note from this exam:
1. 4 round bright white things in the middle of the pelvis on the frontal view that change position on the view with the patient on his side and move to the back of the pelvis in the side view taken with the patient on his back. This suggests that those 4 round things are inside the bladder, and are rolling to whatever part of the bladder is closest to the center of the earth.
2. A large gray round thing in the pelvis that probably represents a large fluid-filled bladder.
3. Multiple round bright white things that project in the place where we would expect to find the urethra.
4. Plates and screws in the bones of the pelvis - mementos of the patient's previous auto accident.
Seeing all these things, I let the ER know that this guy had metallic foreign bodies in his urethra that are obstructing his bladder. Some of the metallic foreign bodies are actually inside his bladder.
On further questioning, it turns out that this guy had, for reasons that are unclear, put magnets up his urethra.
I guess he was bored, and didn't have a pencil.
Urology was called, and they tried to remove the metallic foreign bodies in the ER, though according to the medical record, they "[had] some difficulty." They took the patient to the operating room for definitive treatment with an endoscope.
And, for the record, this is the same guy who dropped all the eggnog in my last post.
More ER stories
"19-year-old man presented after an injury suffered while swordfighting." I was expecting a stab wound, but it turns out that he just dislocated his shoulder while thrusting and twisting. Kind of an unusual mechanism for a shoulder dislocation.
"42-year-old man was riding his skateboard while carrying 20 dollars worth of eggnog. He accidentally tripped and lost all the eggnog on the street. He became angry with himself and hit his head with the metal skateboard, resulting in a laceration to the middle of his forehead."
"57-year-old man was at home, got 'bored,' and shoved a pencil up his urethra." Ouch! He wound up with a lot of blood in his bladder, and a severely bruised ego. He was embarrassed to talk to me about the injury, as he should be - he is old enough to know better, especially since this is not the first time he has injured himself this way. Unfortunately, he is mentally ill, which explains why he has this bad habit.
I had another patient the other night who has chronic bipolar disorder. He came in with a vague history of having been assaulted, with no feeling or movement in his legs. He seemed a lot less concerned about this than I was - I offered to do a lumbar puncture to help investigate what could be causing his illness, and he declined because "I just need to take my medication and my legs will get better." He then said, "Dr. X says that the more I walk, the more paralyzed I become, so there is nothing I can do to make it better. I just have to keep on keeping on, you know." He was not making much sense. Fortunately, we were able to talk him into getting the study - I hope that he has received the surgery he needed to restore feeling and movement in his legs.
A lot of my patients are mentally ill, and the mentally ill are at high risk of bad medical care for the following reasons, among others:
"42-year-old man was riding his skateboard while carrying 20 dollars worth of eggnog. He accidentally tripped and lost all the eggnog on the street. He became angry with himself and hit his head with the metal skateboard, resulting in a laceration to the middle of his forehead."
"57-year-old man was at home, got 'bored,' and shoved a pencil up his urethra." Ouch! He wound up with a lot of blood in his bladder, and a severely bruised ego. He was embarrassed to talk to me about the injury, as he should be - he is old enough to know better, especially since this is not the first time he has injured himself this way. Unfortunately, he is mentally ill, which explains why he has this bad habit.
I had another patient the other night who has chronic bipolar disorder. He came in with a vague history of having been assaulted, with no feeling or movement in his legs. He seemed a lot less concerned about this than I was - I offered to do a lumbar puncture to help investigate what could be causing his illness, and he declined because "I just need to take my medication and my legs will get better." He then said, "Dr. X says that the more I walk, the more paralyzed I become, so there is nothing I can do to make it better. I just have to keep on keeping on, you know." He was not making much sense. Fortunately, we were able to talk him into getting the study - I hope that he has received the surgery he needed to restore feeling and movement in his legs.
A lot of my patients are mentally ill, and the mentally ill are at high risk of bad medical care for the following reasons, among others:
- It is hard to get a reliable, believable history from a patient who believes that aliens have implanted probes in his brain, for example.
- The mentally ill do not necessarily cooperate with physical exams.
- Mentally ill patients do weird things to themselves and thus suffer weird injuries.
- The mentally ill often do a poor job of following instructions after care (taking medicine, etc.)
- Doctors kind of feel uncomfortable about treating the mentally ill, because of concerns that the patient will be dangerous, and because it is kind of icky to talk to them.
- The mentally ill often fall down the socioeconomic ladder as a result of being unemployable and making poor economic decisions, and thus wind up compounding the medical disadvantages of mental illness with all the medical disadvantages of poverty.
20090213
Snort, chuckle, snort
This is a classic case. This man came in after doing something stupid while intoxicated on cocaine. Can you guess what stupid thing he did, and where?
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