WhiteCoat

What’s the Diagnosis #16 — Mmmmm, Eggs

sausages_scrambled_eggsThis is an interesting case for a number of reasons.

First, it shows how a little testing can turn into a lot of testing to “rule out” diseases in the emergency department.
Second, it hopefully provides some good teaching points.
Third, the comment from the attending physician gave me the giggles. That will explain the title. But you have to read through the case to understand the comment.

I’m not going to discuss all the minute details of the case, only the major findings that contribute to the flow of the case.

A patient got sent in from the nursing home because her gastrostomy tube was leaking blood and the nursing home was convinced that the patient was having GI bleeding. When the bandage over the patient’s G-tube was removed, it was fairly obvious that the skin about the G-tube site was the source of the blood. The skin was raw and was oozing dark red blood. Flushing the G-tube produced a little blood, but the blood cleared. The patient’s vital signs were stable except for a mildly elevated pulse. Proper skin care probably would have resolve the bleeding. Some people may have left it at that and sent the patient back to the nursing home. I drew labs and did an abdominal series.

The patient was mildly anemic. Her hemoglobin was 11. There was no blood in her stool. Her BUN was mildly elevated at 24 which suggested that she was behind in her fluids but not that she was having a significant upper GI bleed. With significant GI bleeds, BUN tends to increase quite a bit when the body digests blood.

Wide Mediastinum on CXRThe abdominal series showed that the G-tube was correctly placed and that there was no free air under the diaphragm. However, the chest x-ray showed another worrisome finding. In the bases of both lungs there was scarring and some placques that went along with the patient’s exposure to asbestos many years ago. However, the patient’s mediastinum was maybe just a lit-tle wide. There are a couple of measurements you can use to make that determination. Width > 8 cm on a PA view of the chest. Ratio of mediastinal width to chest width > 0.38. We used to say if the width of the mediastinum on the x-ray film was greater than the width of your pager, that was a problem. Now the youngsters don’t even know what a “hot light” is and some of them haven’t even heard of a pager. How wide is an iPhone these days?
Anyway, if the mediastinum is wide, there are several significant life threats that need to be at least considered. Aortic aneurysmaortic dissection, and cancer are probably the most concerning to the emergency physicians. CT scan of the chest with contrast is one way to test for those conditions.
So the patient with a minor G-tube problem was now getting a CT scan of the chest. Obviously something that many would consider an “unnecessary test” for the complaint of a GI bleed, but a rabbit hole that warrants jumping into during the workup of a markedly abnormal chest x-ray.
Because the GFR was a little low, the patient got extra IV fluid before the scan to try to avoid contrast nephropathy.

CT scan distended esophagus achalasiaThe CT scan of the chest comes back with a little surprise. The aorta was OK, but there was another reason for the patient’s wide mediastinum. The patient had a diagnosis of achalasia and wasn’t supposed to be eating anything. Turns out that the nursing home staff was giving her treats every now and then when the patient would complain about being hungry.
The reason for the patient’s widened mediastinum was that there was a HUGE esophagus and that the esophagus was full of undigested food. See the arrows on the CT scan.
So now we know the reason for the patient’s widened mediastinum.
I called up the patient’s nursing home doc. He agreed that the patient would need to be admitted for management of the achalasia in addition to further evaluation of the possible GI bleeding.
Then he cracked a comment that made me laugh. When discussing the consults that he wanted on the case, he mentioned “Oh yeah, and you better get GI on the case, too. There’s no sense in leaving all that food in there … unless you want to make a fricking winter sausage or something.” Yes, I almost hurled the eggs that I had eaten for breakfast that morning. Then I laughed.
Before the patient was brought to the floor, I checked on her to see how she was doing.
“Can I have a little water?” She asked.
“How about I get you some ice chips for now,” I said.
“And a few graham crackers? She continued.
“Nothing to eat for now, OK?”
Mmmmm. Graham cracker sausage and eggs.

Of course after I told everyone about the sausage comment, no one felt very much like eating lunch. And the rest of the day we’d walk by each other in the hall saying “mmmmmmmm” and giggling at each other.
No, dear patients sitting in the hallway and giving us odd looks, we’re not crazy. Just a little weird.

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One favor for those of you who got this far. I’m changing a few things on the blog soon and would like some feedback to help guide me on the changes. Cases like this take extra time for me to write, review, and reference. This post took me almost 2.5 hours to write. I know that both medical providers and patients read this blog, so I’m wondering whether you felt it was worthwhile.
I want to try to hit a sweet spot between posts like this being informative for providers but not so technical that patients don’t enjoy them. Please answer truthfully – you won’t hurt my feelings.
Any comments about how to make posts like this better would also be appreciated. Straight up cases? More patient interactions? Pictures? No pictures? More links? Less links?
Also, if you have an interesting case you want to write up and post, drop me an e-mail. I guarantee anonymity and HIPAA compliance.

What do you think of case presentations like these?

  • I am a patient and the content was interesting (36%, 176 Votes)
  • I am a medical provider other than a doctor and the content was a good review (35%, 173 Votes)
  • I am a doctor and the content was a good review (21%, 104 Votes)
  • I am a medical provider other than a doctor and the content was too basic (3%, 15 Votes)
  • I am a doctor and the content wasn't covered in enough depth (2%, 11 Votes)
  • I am a medical provider other than a doctor and the content wasn't covered in enough depth (1%, 4 Votes)
  • I am a doctor and the content was too basic (1%, 4 Votes)
  • I am a doctor and content like this doesn't interest me (0%, 2 Votes)
  • I am a medical provider other than a doctor and content like this doesn't interest me (0%, 1 Votes)
  • I am a patient and the content wasn't interesting because it was over my head (0%, 1 Votes)
  • I am a patient and content like this in general just doesn't interest me (1%, 0 Votes)

Total Voters: 491

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

20 Responses to “What’s the Diagnosis #16 — Mmmmm, Eggs”

  1. Wayne Conrad says:

    Dr. Whitecoat, I may have mis-voted. Check for hanging chads :)

    I meant to vote “I’m a patient, and this is very interesting to me,” but I don’t see that vote represented in the counts.

  2. whitecap nurse says:

    You have two identical options and no option for non-doctor medical person/NOT a good review

  3. Lisa K. says:

    I tend the follow the details of cases well enough. Where I sometimes get lost is in the xrays, ct scans, ekgs, etc. Would it be possible to post a normal picture next to the abnormal picture so those of us who don’t know what normal looks like can compare and contrast?

  4. Dork Chocolate says:

    As someone who’s made link sausages before, I found it both disgusting AND hilarious. And as a non-medical person, I agree with Lisa’s request for occasional normal images for comparison. But overall, I enjoy hearing about your interesting cases and patient interactions the most.

  5. Ann Onny says:

    I’ve been a member of your audience since the WP days. Your case studies are something I look forward to, especially the Guess the Diagnosis items. I have learned a lot from these posts and their ensuing discussions.

    I have never read one of these and been hungry for (more?) pictures. You seem to have a good sense of when a picture is necessary and helpful, and when it’s not.

    I’ve noticed that you’ve been more conscientious about linking lately, but you’ve never been lacking in links, even when they just went to the free dictionary site. Frankly, links are convenient (Rereading this phrase and thinking, “hotdogs, sausages”, so thanks) but there’s nothing to stop your reader from copying a phrase and dropping it into Google if they’re confused.

    These types of posts are a real treat; even though I’m not a physician or even a professional, I enjoy the technical details. I’d be bored here if you generalized it.

    I really miss the biting wit and bad behavior of the WP days, by the way.

  6. Nick says:

    Why not med student option!

  7. Nate says:

    I’m a third year med studnet and I think your post are a perfect balance. Much more memorable that didactics!

  8. Rocketman says:

    I like the case presentations. I like the pictures. Personally I don’t need all the links to more info- they’re appreciated, but google will get the job done and you’ll save some time.

  9. Student Paramed says:

    I love the interesting-links-from-around-the-world mash ups. It’s always interesting when my country pops up and I’m all “I didn’t know that!”
    This story was pretty funny though. Keep up the good work!

  10. A Random Person says:

    I like the case presentations – they’re fun for me as a non-medical but generally interested person.

    My one suggestion would be on the diagnoses which you suggest that people guess and then you respond a few days later, would be to put your answer in a separate post. I read from a feedreader, and I always miss out on the answer. :(

  11. Kimalleydvm says:

    I’m a veterinarian so none of the options really fit me. (I voted as a medical provider other than a doctor because I took doctor to be M.D.) Found your blog through an internmate who read your blog for giggles on slow overnight shifts. It’s interesting seeing the differences between our medical practices (and the similarities!) I like the what’s your diagnosis sections because my training lets me make a close guess more often than not.

  12. J says:

    Hey! I’m calling for a medical student option. I think it’s perfect. Thanks for putting the time in.

  13. susanders says:

    I am a Clinical Medical Librarian who attends inpatient rounds with Medical Students at a teaching hospital. In reading your posts, I gain insight about how doctors think, as well as interesting cases. You write clearly, and I appreciate your valuable work!

  14. RadTechSJ says:

    I’m a x-ray tech and I love coming to your website and reading your posts. I really enjoy the imaging used! Always entertaining and informative posts.

    I also like the links your provide with more information. Works well. Keep up the excellent work.

  15. TForney PA-S says:

    I am a second-year PA Student and I always enjoy your case studies. The pictures are great, and serve to explain both your thought process and decision making. Imagine if this patient’s G-Tube wasn’t bleeding, and she eventually developed aspiration pneumonia or an esophageal fistula or perf in the nursing home. Yikes!

  16. I read all posts on your blog. Most interesting are the patient stories. I appreciate the time you put into writing. I have learned many things I am glad to know.

  17. Beth says:

    Great case. I’m a med/peds PCP and think they are delightful. Keep em coming!

  18. RuthieH says:

    I’m a med provider other than a doc. Love your blogs. Thanks for keeping us informed with humor. I think everything balances. You are much appreciated!

  19. geena says:

    I thought it was interesting. I liked the pictures, enjoyed the writing, but usually never click on the links. I’m a nurse.

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