Interesting Cases in ED: Beginning of Final Week

1) Don't trust nurses (specifically new/student). Doctors must see patients for themselves. A middle-aged Malay man was initially laughed at by student nurses for being "funny", and so no doctors were alerted. We just saw another patient, and the MO was busy keying in his details and ordering investigations. I decided to see this new patient, while a student nurse decided to follow me.

I asked his name and age; he doesn't know. I asked where he is; he doesn't know. I asked who is she (the student nurse) is; he answered that he isn't sure, but she isn't his daughter. He thinks I'm a lecturer. He doesn't know the day as well, only that it's a work day. I asked how did he get here; he answered that he only remembers driving here, but nothing else. Then I asked him to lift his left hand; the opposite went up instead.

Immediately I looked as his pupils; they were 3/3 reactive. I asked him to touch his chin to his chest; he couldn't reach it. I tried pushing gently and he complained of neck pain. I palpated his neck; it was tender near his occiput. I tried doing the Kernig test; he said that his "hip" felt painful. I asked him to show me where, and he pointed to his back. Huh.

I asked him if he had fever. No answer (blank stare). Nausea/vomiting? Just groans. Joint pains/rashes? "Entah..." (dunno). I went to the staff nurse in charge (your best ally), informed her and advised her to wear a mask. I enquired about his vitals to the student nurses; they were still stable. Laughing, I told them that he's meningitis (which shut 'em up pretty well). I went and told the MO in charge of yellow (where we were at today).

He went with me, and there he was shivering like having a fit. We immediately pushed him to red, and informed the MO in charge there. The medical MO was informed and admitted the patient with plan for LP for definitive diagnosis.

Looks like I've seen/diagnosed more cases of meningitis in 2 weeks in Serdang than I've ever seen in almost 2 years in clinical medicine (zero). Damn it's creepy.

And never trust patients. They either lie, or talk differently from what they mean. Always ask the patient to point to the site of interest. Ask them what they mean by their "terms".

2) A 30 year old Malay woman complained of epigastric pain for 3 days duration, followed by very sudden generalized abdominal pain which was worse at the lower abdomen on day of admission. The epigastric pain radiated to the back, described as dull pain. There was pain on deep breathing. No history of gastritis, no nausea/vomiting, no bowel habit alteration. No urinary tract symptoms. No fever. Just pain.

She has a history of LSCS done 9 years ago, and her last LMP was 1 week ago. Ex-smoker, non-alcoholic. Patient was writhing and moaning, cursing of pain (pain score of 10). Not dehydrated, pink. Tachypnea with shallow breaths. Examination revealed guarding, tenderness + rebound tenderness, highest at lower abdominal regions.

I suspected a PGU (perforated gastric ulcer), while the MO thought of maybe something else. Surgical referral was made, with chest + abdominal radiographs done. Chest X-Ray initially showed air under the diaphragm, while abdominal X-Ray showed suspicion of dilated large + small bowel. However, a repeated chest X-Ray with air syringed into the stomach via NG tube showed that the "air" became smaller, and thus surgical team concluded that it was unlikely. By this time, UFEME results returned, revealing blood, WBC's and nitrite. A provisional of UTI was made by the surgical team with referral to the medical team, but I thought still of PGU, my MO of perforated small bowel, another of PGU like me, while boss thought of the possibility of ectopic, though unlikely especially with negative UPT. She tried to get a radiological opinion of the initial chest radiograph, but no radiologists could be contacted at the time. And thus even though her clinical state has improved, her definitive "diagnosis" was still uncertain. Heck, even amylase was raised (almost to 250).

Question: Is it possible to have a "false positive" air under diaphragm? Googling failed me. Here's the initial radiograph:

3) Hm, another young male with no known history of medical illnesses came with tingling of fingertips and toes. Appeared hyperventilating. Tingling disappeared with reassurance to breath normally, just waiting for normal blood electrolytes investigation for discharge. Are today's men becoming baby boys? Hehe...This was the 2nd case of male hyperventilating from "anxiousness" in the week.

4) Elderly male came in with constitutional symptoms, and history suggestive of dysphagia, constipation & melena. But he was generally stable and actually quite cheerful. Examination was unremarkable, with no melena as well. Chest radiograph showed local consolidation in the middle zone of the right lung, and reporting was requested for expert opinion. How was the best way to manage the follow-up: specialist clinic/KK? The MO in charge opted for neither, telling him to come again to the green zone (!) in a week. This was to make it easier (and certainly faster than going to the KK) to present the radiological report from the radiologist and correlate it clinically.