The Lion’s Roar

"Roooaaarrrrrrrrr!"

"What was that?" I said to the nurse sitting next to me.
"It sounded like it came from the patient behind you," said the nurse.
I spin around in my chair. My eyes make contact with an elderly man lying in bed. His hair is white and reminds me of Albert Einstein, the way it sticks up from his head. He is covered in a white blanket. I walk over to find out more.
I check his chart. "Mr. Altman, what brings you to the hospital today?" I ask.
He responds after a 5-second delay. "My head. It is pounding. Right here," Mr. Altman said as he pointed to a small spot on the right side of his forehead about 3 inches above his eyebrow. "I've never had pain like this before; never a migraine, not even a headache. I don't know what is wrong but I just don't feel well," he says.
"What was that roar I heard before?" I asked.
"What roar?" he replies.
I decide not to pursue the issue.
I look at the man standing next to Mr. Altman. "Hi, I am Steve, Mr. Altman's son."
"Hi, Steve. Can you tell me more about your father's headache?"
"Well, I noticed my father was not acting like himself this evening. He seemed confused. He forgot my name and didn't know the date. This is unusual. He never complains either. You know, he survived the Holocaust."
I performed a quick physical exam on Mr. Altman, focusing on the neurological aspects. I asked him to smile, raise his eyebrows, puff out his cheeks, and stick out his tongue--looking for the slightest imperfection to signal a neurologic dysfunction. He performed all of these functions perfectly. Then I tested his motor skills. I asked him to push, pull, and raise various parts of his body against resistance. Again, all was normal. I cannot isolate a neurologic abnormality and therefore decide to order a head CT scan and alert the stroke team of a possible stroke.
I wheeled Mr. Altman across the hall to the CT scanner. The radiology technician positioned the stretcher next to the CT table. We slid Mr. Altman onto the table and strapped him in. We placed folded sheets on each side of his head so it does not move--careful to avoid streak artifact and degrade the quality of the scan. We double check to make sure everything is in place and leave the room.
The tech entered the orders into the computer and told Mr. Altman to hold still. "Don't move even an inch," the tech says over the loudspeaker. The large mouth of the CT scanner swallows Mr. Altman. We all watch as the images appear slice by slice.
"Oh boy," I say to myself. "That does not look good!"
Mr. Altman's brain was being compressed by an epidural hematoma. The blood is located exactly where Mr. Altman pointed to when we spoke just minutes ago. If this condition is not corrected, Mr. Altman's brain will start to herniate through the foramen magnum, leading to rapid decompensation and likely death. We don't have much time.
The tech walks over to open the door. I see him struggling with it so I ask what is happening. He says he cannot open the door. It is jammed. "What do you mean?" I ask. I push past him, and wiggled the handle and thrust my shoulder against the door. It doesn't budge. It's clear the door is not jammed, but locked.
"Who has the key?" I ask the tech.
"What key?" he replies, dead serious. "I never lock this door. I have never even seen a key ever used in this door."
I peered into the room through the glass window and saw Mr. Altman lying on his back on the CT scanner table. He doesn't know we can't get him out.
"Call security," I said. "Maybe they have a key."
Security arrives minutes later with a ring of keys.
"Are you going to save the day?" I ask the guard. "Please tell me that one of those keys will open this door!" Five minutes and at least 20 keys later, I asked the clerk to call the fire department. "We need this door open now."
While we waited for the fire department, we kept checking on Mr. Altman. We told him over the speaker not to worry, we are going to get him out soon. He doesn't respond. We can barely see his face because he is lying on his back inside the CT scanner. I started thinking about his brain filling with blood, pressure quickly building, causing his breathing to gradually slow and eventually stop. This man survived the Holocaust, I say to myself; he can hold out a few more minutes. I tried to see his chest rising but he is covered with so many sheets. I kept watching and waiting.
I decided not to wait any longer.
A security guard and I rammed our bodies into the door. It didn't budge. We took a few steps back to get some momentum, and then both of us hit the door at the same time. Nothing. I peer into the room and see Mr. Altman's face. His eyes are closed and I still can't tell if he is breathing. I look at the security guard and tell him we have to get this door opened. We raised our legs and kicked the door as hard as possible. I heard a crack. We kicked it again and again. Finally the door swung open. I rushed over to Mr. Altman's side. As I pulled down the blanket that partially covered his face all I hear is "Rooooaaaarrrrr," coming from the mouth of Mr. Altman. Again, I am not sure what this is. I check his vital signs, which are unchanged.
We returned to the emergency department and called the neurosurgeons so that they could operate on Mr. Altman's hematoma. I explained the diagnosis to Mr. Altman's son and briefly discussed the next steps. I shook the son's hand and wished him luck. Just as I am about to walk away to see my next patient, I stopped and turned around. "Have you ever heard your father roar before?" I ask.
"Oh, his yawn," the son said. "He's been doing that his whole life. He kind of sounds like a lion, doesn't he?"
I nod. He sure does.
[Ann Emerg Med. 2009;54:625-626.]


The Lion’s Roar

“Roooaaarrrrrrrrr!”

“What was that?” I said to the nurse sitting next to me.
“It sounded like it came from the patient behind you,” said the nurse.
I spin around in my chair. My eyes make contact with an elderly man lying in bed. His hair is white and reminds me of Albert Einstein, the way it sticks up from his head. He is covered in a white blanket. I walk over to find out more.
I check his chart. “Mr. Altman, what brings you to the hospital today?” I ask.
He responds after a 5-second delay. “My head. It is pounding. Right here,” Mr. Altman said as he pointed to a small spot on the right side of his forehead about 3 inches above his eyebrow. “I've never had pain like this before; never a migraine, not even a headache. I don't know what is wrong but I just don't feel well,” he says.
“What was that roar I heard before?” I asked.
“What roar?” he replies.
I decide not to pursue the issue.
I look at the man standing next to Mr. Altman. “Hi, I am Steve, Mr. Altman's son.”
“Hi, Steve. Can you tell me more about your father's headache?”
“Well, I noticed my father was not acting like himself this evening. He seemed confused. He forgot my name and didn't know the date. This is unusual. He never complains either. You know, he survived the Holocaust.”
I performed a quick physical exam on Mr. Altman, focusing on the neurological aspects. I asked him to smile, raise his eyebrows, puff out his cheeks, and stick out his tongue—looking for the slightest imperfection to signal a neurologic dysfunction. He performed all of these functions perfectly. Then I tested his motor skills. I asked him to push, pull, and raise various parts of his body against resistance. Again, all was normal. I cannot isolate a neurologic abnormality and therefore decide to order a head CT scan and alert the stroke team of a possible stroke.
I wheeled Mr. Altman across the hall to the CT scanner. The radiology technician positioned the stretcher next to the CT table. We slid Mr. Altman onto the table and strapped him in. We placed folded sheets on each side of his head so it does not move—careful to avoid streak artifact and degrade the quality of the scan. We double check to make sure everything is in place and leave the room.
The tech entered the orders into the computer and told Mr. Altman to hold still. “Don't move even an inch,” the tech says over the loudspeaker. The large mouth of the CT scanner swallows Mr. Altman. We all watch as the images appear slice by slice.
“Oh boy,” I say to myself. “That does not look good!”
Mr. Altman's brain was being compressed by an epidural hematoma. The blood is located exactly where Mr. Altman pointed to when we spoke just minutes ago. If this condition is not corrected, Mr. Altman's brain will start to herniate through the foramen magnum, leading to rapid decompensation and likely death. We don't have much time.
The tech walks over to open the door. I see him struggling with it so I ask what is happening. He says he cannot open the door. It is jammed. “What do you mean?” I ask. I push past him, and wiggled the handle and thrust my shoulder against the door. It doesn't budge. It's clear the door is not jammed, but locked.
“Who has the key?” I ask the tech.
“What key?” he replies, dead serious. “I never lock this door. I have never even seen a key ever used in this door.”
I peered into the room through the glass window and saw Mr. Altman lying on his back on the CT scanner table. He doesn't know we can't get him out.
“Call security,” I said. “Maybe they have a key.”
Security arrives minutes later with a ring of keys.
“Are you going to save the day?” I ask the guard. “Please tell me that one of those keys will open this door!” Five minutes and at least 20 keys later, I asked the clerk to call the fire department. “We need this door open now.”
While we waited for the fire department, we kept checking on Mr. Altman. We told him over the speaker not to worry, we are going to get him out soon. He doesn't respond. We can barely see his face because he is lying on his back inside the CT scanner. I started thinking about his brain filling with blood, pressure quickly building, causing his breathing to gradually slow and eventually stop. This man survived the Holocaust, I say to myself; he can hold out a few more minutes. I tried to see his chest rising but he is covered with so many sheets. I kept watching and waiting.
I decided not to wait any longer.
A security guard and I rammed our bodies into the door. It didn't budge. We took a few steps back to get some momentum, and then both of us hit the door at the same time. Nothing. I peer into the room and see Mr. Altman's face. His eyes are closed and I still can't tell if he is breathing. I look at the security guard and tell him we have to get this door opened. We raised our legs and kicked the door as hard as possible. I heard a crack. We kicked it again and again. Finally the door swung open. I rushed over to Mr. Altman's side. As I pulled down the blanket that partially covered his face all I hear is “Rooooaaaarrrrr,” coming from the mouth of Mr. Altman. Again, I am not sure what this is. I check his vital signs, which are unchanged.
We returned to the emergency department and called the neurosurgeons so that they could operate on Mr. Altman's hematoma. I explained the diagnosis to Mr. Altman's son and briefly discussed the next steps. I shook the son's hand and wished him luck. Just as I am about to walk away to see my next patient, I stopped and turned around. “Have you ever heard your father roar before?” I ask.
“Oh, his yawn,” the son said. “He's been doing that his whole life. He kind of sounds like a lion, doesn't he?”
I nod. He sure does.
[Ann Emerg Med. 2009;54:625-626.]

MH#4




Half of what you learn in medical school would prove to be wrong in ten years 


-Dr Sydney Burwell, Dean Harvard Medical School 

MH#4




Half of what you learn in medical school would prove to be wrong in ten years 


-Dr Sydney Burwell, Dean Harvard Medical School 


Intern Report Case Presentation 4.3

Case Presentation by Dr. Dan Helzer

HPI 
36 year old AA female presents to the emergency department complaining of “passing out.”  Pt states that she was sitting down watching TV when she stood up, became very dizzy and lightheaded but no vertigo and fell to the ground.  She stated that she remembers almost everything but could not stay standing up for some reason.  Family members stated that she was not arousable for a few seconds and then came too.  She felt uneasy as family members helped her up and needed assistance getting into the car to be brought to the ED.  She has felt a little weak over the last few days but has experienced nothing like this recently.  Pt also states that she has had heavy vaginal bleeding for the last 10 days, it began with her normal menses but never stopped.  Her last normal menstruation was a month and a half ago.  Typically she has heavy menses but it only lasts 3-4 days.  She says that currently she is passing large clots and goes through multiple pads daily.  She denies headaches, abdominal pain, chest pain, palpitations, and SOB.  She denies ever being told that she has an abnormal heart beat or problems with her heart.  Her family denies any bladder or bowel incontinence during the event.

Past medical history is significant for anemia and fibroid uterus.  Pt is G3P3 and is sexually active.  Her medications include Fe pills.

Past surgical history positive for C-section x 2.

Social Hx includes a 30 pack/year smoking history.

PE
Vitals:  108/55, HR 104, RR 16, Pulse Ox 99 % on RA, Temp 37.7

General:  Pt is in no acute respiratory distress, appears pale.

HEENT: Normocephalic/atraumatic, PERRLA, EOMI, no nystagmus, conjunctiva pale and non-icteric, mucous membranes moist and pale.  Fundoscopy demonstrated no pappiledema.  

Neck: No lymphadenopathy, no JVD, no masses

Respiratory and Lungs: Equal excursion bilaterally, CTAB, no wheezes, rales, rhonchi, or stridor.

Cardiovascular and Heart: Tachycardic rate and rhythm, S1/S2 auscultated, no murmurs, gallops, rubs, or thrills.  Pulses palpated in all 4 extremities. 

Gastrointestinal and Abdomen: BS +, Abdomen soft, non-tender, non-distended.  No masses.  No CVA tenderness. 
Neurological: Patient is alert and oriented to person place and time, CN II-XII intact, sensation to pinprick intact in all 4 extremities, strength 5/5 in all extremities.  No pronator drift was present. Reflexes are 2+.  Heal to shin was normal.  Upon standing pt became lightheaded and dizzy and felt the need to sit back down, therefore gait and Romberg were not properly evaluated. Dix-Hallpike test was normal.   

Genitourinary:  External genitalia were normal. Examination of the pelvis and vagina revealed active bleeding from the closed cervical os with pooling of blood and blood clots in the vaginal vault, no tissue like material was present.  The uterus was not enlarged.  CMT was absent.  The adnexa were non-tender and no masses were palpated. 

Orthostatic Vital Signs:
-Supine BP 109/60, HR 103
-Sitting BP 100/59, HR 111
-Standing BP 88/52, HR 127  
Lab Results:
Urine pregnancy negative
WBC 11.3, Hemoglobin 2.9, Hematocrit 11.7, Platelets 35
Electrolytes all WNL 

Diagnostic Studies:

12 Lead ECG:  Sinus Tachycardia at 107 BPM.

Ultrasound showed?
 Version:1.0 StartHTML:0000000175 EndHTML:0000014694 StartFragment:0000003558 EndFragment:0000014658 SourceURL:file://localhost/Users/adamrosh/Desktop/Syncope%20Case.doc
Pelvic US with Duplex: 

Findings suspicious for adenomyosis.
Nabothian cyst in the cervix largest measuring 0.7 x 0.5 x 0.8 cm
Paraovarian cyst adjacent to left ovary.

Questions: 

1.     What is the most common cause of syncope in adults aged 18-65 who present to the ED?
A.   Postmicturation
B.    Orthostatic
C.    Psychogenic
D.   Unknown or Idiopathic
E.    Cardiac
2.     The same pt is brought in by family members who tell you that when she fell down after standing up her whole body started shaking for at least one minute and she was completely unresponsive during this time. They said it looked just like a seizure that the patient’s cousin with epilepsy has all the time.  Which clue in the HPI can often be the only distinguishing feature between syncope and seizure?
A.   The patient has never had a seizure before
B.    The patient remembers everything
C.    The patient has an abrupt and complete recovery to baseline
D.   The patient has generalized tonic/clonic movements during the episode.
E.    The patient ate 10 tacos from taco bell and drank a liter of cola earlier in the afternoon.
3.     Of the following, which pt with syncope should be discharged from the ED with follow up by PCP and not be admitted.
A.   A 17 year old male with exertional syncope and crushing chest pain. 
B.    A previously healthy 37 year old male with 5 seconds of asystole on carotid sinus massage.
C.    Our patient with a hematocrit of 11 and orthostatic hypotension
D.   A 90 year old female with an EF of 22% and enlarged heart borders on CXR
E.    A 52 year old male with SOB on initial presentation.

Please submit your answers as a comment. Your submission will not immediately post. Answers with a case discussion will post on Friday. If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report 

Intern Report Case Presentation 4.3

Case Presentation by Dr. Dan Helzer

HPI 
36 year old AA female presents to the emergency department complaining of "passing out."  Pt states that she was sitting down watching TV when she stood up, became very dizzy and lightheaded but no vertigo and fell to the ground.  She stated that she remembers almost everything but could not stay standing up for some reason.  Family members stated that she was not arousable for a few seconds and then came too.  She felt uneasy as family members helped her up and needed assistance getting into the car to be brought to the ED.  She has felt a little weak over the last few days but has experienced nothing like this recently.  Pt also states that she has had heavy vaginal bleeding for the last 10 days, it began with her normal menses but never stopped.  Her last normal menstruation was a month and a half ago.  Typically she has heavy menses but it only lasts 3-4 days.  She says that currently she is passing large clots and goes through multiple pads daily.  She denies headaches, abdominal pain, chest pain, palpitations, and SOB.  She denies ever being told that she has an abnormal heart beat or problems with her heart.  Her family denies any bladder or bowel incontinence during the event.

Past medical history is significant for anemia and fibroid uterus.  Pt is G3P3 and is sexually active.  Her medications include Fe pills.

Past surgical history positive for C-section x 2.

Social Hx includes a 30 pack/year smoking history.

PE
Vitals:  108/55, HR 104, RR 16, Pulse Ox 99 % on RA, Temp 37.7

General:  Pt is in no acute respiratory distress, appears pale.

HEENT: Normocephalic/atraumatic, PERRLA, EOMI, no nystagmus, conjunctiva pale and non-icteric, mucous membranes moist and pale.  Fundoscopy demonstrated no pappiledema.  

Neck: No lymphadenopathy, no JVD, no masses

Respiratory and Lungs: Equal excursion bilaterally, CTAB, no wheezes, rales, rhonchi, or stridor.

Cardiovascular and Heart: Tachycardic rate and rhythm, S1/S2 auscultated, no murmurs, gallops, rubs, or thrills.  Pulses palpated in all 4 extremities. 

Gastrointestinal and Abdomen: BS +, Abdomen soft, non-tender, non-distended.  No masses.  No CVA tenderness. 
Neurological: Patient is alert and oriented to person place and time, CN II-XII intact, sensation to pinprick intact in all 4 extremities, strength 5/5 in all extremities.  No pronator drift was present. Reflexes are 2+.  Heal to shin was normal.  Upon standing pt became lightheaded and dizzy and felt the need to sit back down, therefore gait and Romberg were not properly evaluated. Dix-Hallpike test was normal.   

Genitourinary:  External genitalia were normal. Examination of the pelvis and vagina revealed active bleeding from the closed cervical os with pooling of blood and blood clots in the vaginal vault, no tissue like material was present.  The uterus was not enlarged.  CMT was absent.  The adnexa were non-tender and no masses were palpated. 

Orthostatic Vital Signs:
-Supine BP 109/60, HR 103
-Sitting BP 100/59, HR 111
-Standing BP 88/52, HR 127  
Lab Results:
Urine pregnancy negative
WBC 11.3, Hemoglobin 2.9, Hematocrit 11.7, Platelets 35
Electrolytes all WNL 

Diagnostic Studies:

12 Lead ECG:  Sinus Tachycardia at 107 BPM.

Ultrasound showed?
 Version:1.0 StartHTML:0000000175 EndHTML:0000014694 StartFragment:0000003558 EndFragment:0000014658 SourceURL:file://localhost/Users/adamrosh/Desktop/Syncope%20Case.doc
Pelvic US with Duplex: 

Findings suspicious for adenomyosis.
Nabothian cyst in the cervix largest measuring 0.7 x 0.5 x 0.8 cm
Paraovarian cyst adjacent to left ovary.

Questions: 

1.     What is the most common cause of syncope in adults aged 18-65 who present to the ED?
A.   Postmicturation
B.    Orthostatic
C.    Psychogenic
D.   Unknown or Idiopathic
E.    Cardiac
2.     The same pt is brought in by family members who tell you that when she fell down after standing up her whole body started shaking for at least one minute and she was completely unresponsive during this time. They said it looked just like a seizure that the patient's cousin with epilepsy has all the time.  Which clue in the HPI can often be the only distinguishing feature between syncope and seizure?
A.   The patient has never had a seizure before
B.    The patient remembers everything
C.    The patient has an abrupt and complete recovery to baseline
D.   The patient has generalized tonic/clonic movements during the episode.
E.    The patient ate 10 tacos from taco bell and drank a liter of cola earlier in the afternoon.
3.     Of the following, which pt with syncope should be discharged from the ED with follow up by PCP and not be admitted.
A.   A 17 year old male with exertional syncope and crushing chest pain. 
B.    A previously healthy 37 year old male with 5 seconds of asystole on carotid sinus massage.
C.    Our patient with a hematocrit of 11 and orthostatic hypotension
D.   A 90 year old female with an EF of 22% and enlarged heart borders on CXR
E.    A 52 year old male with SOB on initial presentation.

Please submit your answers as a comment. Your submission will not immediately post. Answers with a case discussion will post on Friday. If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving's: Intern Report