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.

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:

• 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.
  

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?