Today I worked up a 50-ish man who was admitted with altered mental status, cystitis and acute renal failure. He'd been in the hospital for just over twenty-four hours without much improvement. He wasn't hallucinating anymore, but restless, agitated, strange.
I was a fourth-year medical student by the time I finally rotated through anesthesiology. Students who suspected they might be interested in entering this specialty scheduled their rotations early in the third year, but crunchy family practice types like me let it slide until fourth year, when you have a bit of medicine under your belt and can kick back and have some fun on a procedure-rich rotation. Yet there are primary-care teaching moments on every rotation, even ones which take place largely in the operating room rather than the clinic. Here's one example:
When I was still doing primary care, one of my patients was a 58 year-old woman with epilepsy, bipolar disorder and hypertension. Her name was Vonnie and her life had been difficult, to say the least. Most of her third decade had been spent in and out of ERs for seizures or psych wards for manic episodes, yet when I knew her these conditions were well-controlled on a complex cocktail of anti-convulsants, anti-depressants and mood stabilizers. The long history of seizures and sedating medicines made Vonnie seem a bit slow at times, but she was always wry and funny in her quiet way.
An 81 year old man arrived in the Emergency Room with subacute onset of shortness of breath. He had a history of Parkinson's Disease and hypertension, neither of which had caused any significant decline in his quality of life although he had noticeable intention tremor when he felt tired.
He'd been hospitalized many years ago for what sounded like a soft tissue abscess that took a long time to heal. After the hospitalization, he and his wife consulted a lawyer for help drafting an Advance Directive:
Recently, we had a 39 year-old man on our hospitalist service who presented with transient hemiplegia, diplopia, and somnolence. A brain MRI showed an acute stroke in the distribution of the thalamo-geniculate pedicle. By the end of his hospitalization, his mental status and motor abilities had normalized but he retained an interesting pattern of aphasia. He had a great deal of word-finding difficulty, although his speech was fluent and he could follow commands easily.
One day, when I was on a very busy hospitalist service, the ER called me with an admission. "I've got a 35 year old woman, shoots meth, smokes, uncontrolled diabetic, comes in with shortness of breath," the harried ER attending reported. "X-ray looks like a bilateral pneumonia, and some parapneumonic effusions too, but not enough to tap. Oh, and she's pregnant, about 14 weeks by LMP. She's stable but the last bed we have is in ICU, so that's where she's going."
Sometimes when I'm the hospitalist it seems as though most of the patients have the same disease or symptom. I call these Theme Weeks. Middle of winter usually features Shortness of Breath Week, but sometimes we have Skin-Popping Abscess Week or Young Men with Rhabdo Week. Around the holidays we also get Suicide Attempt Gone Awry Week. Most of the time, I find Theme Weeks amusing, in a dark way, but sometimes they are sad and wonderful, as they were during the Metastatic Cancer Week I had not long ago.
One day I was trying to get ready to go to the hospital when I got a page. It was one of the orthopedic surgeons asking me to consult on a patient.
"The nurses called me and they're freaking out," said the orthopod. "The guy threw up red stuff and they're afraid he's got a GI bleed. I'm supposed to take him to the OR at nine-thirty."
I hate it when I have to clear a patient for surgery on extra-short notice. I got the hospital and was relieved to see he was a young, otherwise healthy man who'd gotten a bit drunk and fallen off a porch. He had a bimalleolar fracture that needed fixing, but what was the deal with throwing up red stuff?
An 88 year-old man traveled from the Silicon Valley to visit friends up here in Rural. After dinner and a couple of glasses of wine, he tripped on a flagstone and broke his right proximal humerus and his right femoral neck. My little hospital had the great pleasure of admitting him.
Almost immediately, his three daughters started calling Med-Surg, providing phone numbers of his primary care doctor, cardiologist, and vascular surgeon. One of them made reference to two episodes of "torsades," although she really didn't know what that meant. They were obviously worried about the prospect of surgery to repair the hip. What was unspoken but equally obvious was their concern about his having surgery at "what's-that-hospital-called?" here in Rural.
One day on hospitalist rounds, I saw the ER had left me an admission from 2am. The sign-out read: "63 year old woman with large breast mass." I wasn't sure what that meant. Perhaps a breast abscess?
The truth was a bit more complicated. I could tell when I entered her room and introduced myself. She emitted an odor I can only describe as living decomposition. A syrupy, cloying smell reminiscent of rotting meat, only worse.
This is a real excerpt from a discharge summary I dictated recently:
This is a nice 88 year old man who returned home from a road trip on the day of admission. He had stayed at a Motel 6 motel in [another town] and had subsequently seen an advertisement offering the chance to win a free stay at the chain of hotels by completing a customer satisfaction survey. When he was within a few blocks of his home, he noticed there was another Motel 6 on his way and decided to go to the motel to obtain a copy of the survey. However, when he made his request at the front desk, the staff at Motel 6 thought he was confused. Specifically, the EMT notes suggested that he kept repeating "town and country, town and country" over and over again; this was taken as a sign of altered mental status even though the patient later explained to me, "They was asking me where I lived, and I told 'em, Town and Country Mobile Home Park." The next thing he knew, he was being taken away by EMTs and brought to the emergency room where, based on the EMT history of "altered mental status," he was admitted for observation...
...After some discussion among the staff and with the patient of the events leading up to his admission, it became apparent that what was described as a confusional state was actually a misunderstanding. The patient--who, at baseline, speaks in a fairly broad Southern accent, is noticeably hard of hearing, and has an extremely discursive conversational style--probably appeared confused to an unfamiliar and inpatient motel staff.
Dx: Slightly befuddled 88 year-old man from Alabama
A 45 year-old man was brought to our hospital via ambulance after being found unresponsive at home. He works as a non-clinical staff member at the hospital and is known and loved by all. En route, he is somnolent, breathing about four times a minute, and has a normal blood sugar.
By the time he arrives in ER, he is on 15L oxygen via a non-rebreather mask. His peripheral O2 saturations are 70% on room air, 94% on the 15L. His core temperature is 88 degrees Farenheit. He is given a dose of Narcan and wakes up briefly, although he immediately dozes off again. His respiratory rate increases from four to ten times per minute and he appears to be guarding his airway. His urine tox is positive for cannabis (almost universal in this county) and methadone. He can't give any history and none of his distraught family can provide me with an accurate medicine list.
