DO NOT COME INTO THE ER AND PRETEND TO HAVE STAGE IV COLON CANCER JUST SO YOU CAN GET DILAUDID. IT IS WRONG. MORALLY REPREHENSIBLE. IT MAKES ME WANT TO GIVE YOU CANCER SO YOU CAN ACTUALLY KNOW WHAT IT FEELS LIKE TO BE IN PAIN. 

So today I had an extremely interesting patient. 
The patient was a Stage IV Lung cancer who got radiation/chemo. He presented with complaints of chest pain and back pain that began suddenly while he was at physical therapy. Other than lung cancer, his only other hx was a cholecystectomy and metaport placement. He was slightly tachycardic betwen 100-110 and was normotensive. His oxygen saturation was low in the lower 90s but he said that was around his normal range and denied no increase in SOB compared from his baseline.  He appeared in moderate distress secondary to the pain. He denies and N/V, fever, cough, pain with breathing. He hadn’t taken any recent trips and was not a smoker. EKG only showed Sinus Tach at 108 with a rightward axis with no evidence of ST elevation, depression, or any other abnormality. With his hx we sent him right to CT for a CTA chest. I normally do a glance through our CT scans for the doctors before we get the radiology reports and this is what I saw:

I’ve posted about this before, but what you see here is called a Pulmonary Embolism (PE). A PE is a blood clot located in the pulmonary arteries and is a pretty serious medical problem and can often lead to death in an acute setting when not treated with anticoagulants (usually Enoxaparim or heparin in the acute setting). The blood clot in the picture is what we like to call a saddle embolus. A saddle embolus is a PE that sits at the bifurcation of the pulmonary arteries and is especially dangerous because it extends into both sides of the bifurcation, leading to an even higher risk of serious problems which all lead to death. Worse also is the fact that the PE is nearly if not 100% occlusive on the left and believe me when I say that the right side wasn’t much better as there was another large PE that you can’t see in this image (you can see it beginning but just barely. I’ll put an annotated picture at the bottom). The patient was quite honestly lucky to be alive at this point and we were pretty surprised that he wasn’t more hemodynamically unstable relative to the severity of his PE.

Anyway, you’re probably thinking what could possibly be the blessing this patient got from his PE. Well there was one thing that the CT didn’t show, a mass. His lung mass, which was compared to prior studies, wasn’t found and even though it had been decreasing in size with his chemo/radiation, was still obvious on an exam 2 months prior. They were so happy to find out the news, even though it came with a PE bundled into the mix.

Overall, I would say that the patient got a pleasant surprise

The arrows point to the filling defects you can see in the pulmonary arteries. The huge one with a pink arrow was the one I was talking about that was nearly 100% occlusive. The arrow that is multicolored is pointing to the bifurcation, where you can see a filling defect on either side (the saddle emoblus) and the other two maroon arrows point to the beginning of another large PE that you can just barely see in this image.

Just got back from a mock medical school interview with the pre-med committee at my school. It went really well (and not so good at the same time). They told me how passionate I was about the field and they could tell it’s what I wanted to do and was dedicated towards pursuing it. They also said they were impressed with how articulate I am about the field especially when they asked me about patient experiences. However, they told me how much of a disconnect there is between myself and my grades.  They reminded me that my grades are going to be my main deterrent from getting into medical school and that it’s going to be much more difficult for me to get in because of them.

The hospital has descended to the point of chaos where code patients are ER holds.

Madness I tell you, madness. 

The hospital is full and literally 90% of the ER beds are taken by patients that are ER holds, meaning that they are admitted but don’t have a bed. About 1/3 of those patients are ICU holds. 

Good thing I’m not at work tonight, although this weekend will probably be worse if this problem isn’t somehow magically fixed

It seems like my black cloud might have jumped ship for a bit!

Before: Child sticks finger in rabbit cage

After: Child is missing part of their finger

Saw a stabbing the other night at work.

He rolled right in through triage after being stabbed 5 times with an unknown object while walking home at 0300. 

CT showed a fairly large pneumothorax as well as a lung/diaphragm laceration. 

So all ER did was put in a chest tube and off to surgery he went.

Pretty exciting and I got shown how to put in a chest tube which was awesome

Case presentation was here

So, most people guessed hyponatremia. Which was a reasonable diagnosis and was one of our differentials but not our first. Sodium levels on the CMP were in the mid 120s. While low, not low enough to cause the memory issues the parents were reporting. 

The patient actually had Wernicke-Korsakoff Syndrome as was shown by her reduced thiamine levels. Although normally seen in alcoholics, it can now be seen in bariatric surgery patients due to malnutrition and is made worse if they don’t follow post op instructions carefully. Thiamine deficiency results in heavy damage to the mammillary bodies of the hypothalamus, as well as damage to the connections between them, the prefrontal cortex, thalamus. Her presentation of symptoms wasn’t so heavy on signs of Wernicke’s encephalopathy, with her only real manifestation being her weakness and ataxia. However, her very interesting story about sally gave a hint towards Korsakoff syndrome. Korsakoff’s syndrome can present with confabulation, where the patient actually believes a false story in lieu of having amnesia about that period of time. The patients don’t know they’re lying and generally and strongly believe that what they’re saying is the truth. They also have problems with anterograde amnesia, on varying levels of severity. Kelly had issues forming new memories and was seen by her inability to remember speaking to her parents only 5 to 10 minutes after their conversations.

Why the thiamine deficiency with her? Thiamine is primarily absorbed in the duodenum, which is bypassed during gastric bypass. Couple this with a probably poor diet before her surgery and the N/V afterwards (extremely common side effect in bariatric surgery of any kind) led to too much of a thiamine deficiency, hence her strong belief that she had gone on a strawberry milkshake ridden adventure.

I gotta give props to WayfaringMD for starting the trend, but here’s a fun way for everyone to get all knowledgeable

Presentation: A younger woman Kelly, in her mid to late 20s presents to the ED with her parents. Per the family, Kelly presents with complaints of amnesia, generalized weakness, and nausea/vomiting for one week. They say that about 2.5 weeks ago their daughter had a gastric bypass due to her weight and everything had been progressing fine until about one week after the surgery when she began vomiting, although they are unsure of a more exact time frame as they both work demanding jobs. They say she slowly had increased generalized weakness and became more bedridden than normal, being unable to get out of bed without their help. This progressed until Kelly was vomiting at least once after every “meal”. Last night, they noticed that she was having some memory problems. She couldn’t seem to remember the events of her day correctly and even seemed to be outright lying. She was adamant that she had driven her friend Sally to the movies that day so they could see a movie they both wanted to see, even though their daughter is to weak to get out of bed…and sally moved to another state three years ago. Kelly would also forget having conversations with her parents just five or ten minutes after having them. While they tell this to you, Kelly adamantly says that she saw sally yesterday and after the movies they went out for Hamburgers and Milkshakes. She says she knows this is true because they both got strawberry milkshakes, which is their favorite flavor.

I think this should be enough to give a good guess
What do y’all think?