Since patients turnover in Surgical Ward aren’t as swift as Medical Ward so we need to fight tooth and nail in getting great cases to be presented…or draw over.
That day, we came for ward work kinda late at 9.30 am (after much café-loitering) everyone else already clerked their patient, and there I was looking for a good candidate. In female ward, I got myself a case of Motor Vehicle Accident on observation for Post-Concussion Syndrome. Dang, we running out new cases of classic abdominal pain, I might as well experiment with this patient. Except for her complaint of dizziness and projecile vomitting, I wouldn’t worry much.
As Dr.T once said “Not every acute appendicitis case the same.” so this what seems to be lame case just turned out to be interesting. This is a case of motor vehicle versus lamp post. The driver is her father and it is his fourth accident. My patient told me that prior to the accident, his father seemed alright and they talked before her father suddenly turned quiet and skidded. He looked wide-awake and conscious with wide open eyes. Just after they crashed, his father regained orientation. He lost the past seconds where he drove onto a lamp post.
There it is, it clicked in my head, ABSENT SEIZURE (a.k.a Petit Mal Seizure). This is not a case of TIA, narcoleptic, apnea or old damn syncope as patient did not lose consciousness, he’s just being ‘not there’. My deepest desire urged me to run upstairs to medical ward, invading other teams territory and clerked her father instead. In case you wonder, yes he is alright, and did not sustained any injury, credit to seatbelt.
According to my patient, his father haven’t been diagnosed. Previous accident never require him to go to hospital. Twice of motorbike, and once of car. Even after the third accident of the same cause, he never seek medical attention regarding his problem. Blaming that he might’ve dozed off. But this fourth accident was witnessed by his daughter (my patient) herself, and she claimed that her father wasn’t dozing off, but like a satellite disk on a rainy fay ‘temporarily not available’. Meaning, his father has been four times lucky, getting absent seizure attack while behind wheel and he still keen to drive. Legally, he should not be allowed to drive at all. He can poses accident threat to himself, his family and other road users. My seemed to be simple case just become super freaking twisted. I was all fired up to run upstairs to 8th floor to see if anywhere in the patient file they successfully diagnosed him with absent seizure. Absent seizure, how rare is that.
Diagnosing is super fun. Anticipating a complexity of a simple case is Gregory House + Sherlock Holmes braingasm. Just like the last time I helped my friend preparing Case Presentation of plain Cholecystitis in a male patient on his 20’s that upon further brainstorming closely resembles a case of Community Acquired Pneumonia (CAP) likely caused by Mycoplasma pneumoniaa. That later triggered Cold Agglutinin (IgM) that cross react with antigens to patient RBCs and rendered them hemolyzed.
Epidemiologically, acute cholecystitis of patient’s in their 20’s likely caused by hemolytic anemia (HA). Calcium bilirubinate more likely. And without referring to case sheet; I expecting this patient having normochromic microcytic anemia, low TRBC count, reticulocytosis, leukocytosis with neutrophilia, and normal RDW. Which turned out to be a super jackpot.
How do I diagnosed CAP, I asked her (my friend) if her patient had cough prior to episode of RUQ pain. Jackpot again, he has cough with yellowish sputum. I was on fire that day, that plus my sleep-deprivation state, working well.
What is it with me and the need to diagnose super-complex case?
Again back to that Thursday, because my patient is an MVA cases, I didn’t have to do any further physical examination. Hahaha…
We were supposed to identify anterior superior iliac spine, iliac crest, McBurney’s point, midpoint of inguinal ligament and mid inguinal point and draw them with permanent marker onto patient’s body, of course with their consent we have not yet shaved off our bedside manners. Those and a proper way to do abdominal examination was supposedly be our graduation ceremony under Dr. T bedside guidance for this third phase. Next we will be taught by HTAR specialists and consultants. I will miss our close-to-three-hour BST with Dr. T, while standing on windy ward balcony, vacillating weight bearing between left and right leg.
2 comments:
nice story...did you manage to get to the patient with Absent seizure?
kinda nice to have that sort of enthusiasm.
that sort of enthusiasm only came when i am sleep deprived. in my normal cycle, i mostly a walking caffeine addict.
nope, but i sure will check on record department about him.
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