# Brown's really awesome super hard scenario



## MrBrown (Aug 24, 2010)

This is a retrospective case and it is intended to be difficult.  You are not expected to "solve" it straight away and it is intended as a teaching tool more than a "look at home hard this is" type of thing.

You are called to a house for an unresponsive male.  Upon arrival your assessment reveals the patient has died.  There is no obvious physical signs of traumatic injury apart from one or two minor skin abrasions on his arms.

*Patient Information*
-Male
-25 years old
-Infrequent use of intravenous recreational drugs

*Recent medical history*
- A week ago the patient was playing basketball with some friends at the Y and suffered what he thought was a back strain when he tripped over and grazed his arm.  He consulted with his Physiotherapist who recommended rest and prescribed Voltarn (diclofenac) and acetamyophen (Panadol) for this.

- Since then the patient stated his pain was getting progressively worse and he spent much of the week in bed and had seen his GP three days ago.  His GP prescribed further painkillers and recommended he see the Physio again.

- Last night the patient went ot the emergency department about 3pm.  

- The Triage Nurse recorded at 3pm that the patient was having difficulty in standing, was nauseated, in 9/10 pain and had the following vital signs:  BP 150/110, RR 40, PR 110, temp 36.1 deg C.  

- The nurse tracked down a third year Registrar (specalist trainee in emergency medicine) and he prescribed PO diazapem, malaxon (metaclopramide) and acetamyophen.  The Registrar dis not see the patient. 

- One of the ED nurses saw the patient again at 3.45pm and took another set of obs.  She noted he had taken the medications that the Registrar had prescribed and was c/o left buttok pain, pain in both legs but worse in left, feeling cold and sore.  Obs were BP 140/100, RR 30, temp 36 and PR 116.

- At 4.10pm a second year House Officer (Doctor with two years of post medical school training who is not a specalist trainee) examined the patient.  She noted that his complaints were sore back, left buttock and posterior thigh pain and feeling cold.  The Doctor found no neurological signs except that the patient had severe difficulty standing or walking and was unable to pass urine when asked for a sample.

- The House Officer found that he had unequal motor power in his legs and was unable to raise his left leg beyond 10 degrees while he could raise the right about 30 degrees.  The patient had an absent left knee jerk upon examination.  

- At 4.30pm the patient was given 10mg of intramuscular morphine and at 6.00m was sent home without being seen by a Consultant.

- During the night the patient stated he felt hot and cold and the sensation in his legs was decreasing.  He died an hour later.

So, what was wrong with this fellow?


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## EmtTravis (Aug 24, 2010)

I am guessing that something happened to his spine.  What happened I am not sure.  I could take many guesses but seeing as how im new in the medical field I don't have the knowledge to answer this scenario.  I will be keeping a close eye on this thread because it interests me.


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## abckidsmom (Aug 24, 2010)

Aneurysm of the descending aorta.


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## Aidey (Aug 24, 2010)

Spinal bleed. As in, bleeding into the spinal column putting pressure on the spinal cord causing progressive neuro deficits, severe back pain, and causing decending pain as the bleeding progresses inferior.


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## abckidsmom (Aug 24, 2010)

Thought about it a little more, and I'm going to change it to a torn renal artery with a retroperitoneal bleed.  A very very small tear, that leaked and tamponaded itself for a week.

And while I'm making this astonishing diagnosis guess, I'm going to high-five myself for getting such a stellar history from a dead guy.  

People in orange jumpsuits always communicate with the dead this well?


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## MrBrown (Aug 24, 2010)

It's not a bleed.

Dead people often relay thier histories to others before they die you know


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## abckidsmom (Aug 24, 2010)

MrBrown said:


> It's not a bleed.
> 
> Dead people often relay thier histories to others before they die you know



Well...It is a great history.  Looking forward to seeing the answer.


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## MrBrown (Aug 24, 2010)

Lets look at this in a macro-level sense; 

1.  This patient has neurological defecit
2.  Assuming his condition did not change between when the last set of obs were taken and when he died; he said he was feeling hot and cold andwas recorded as being tachycardic.  

What could these two mean if we consider them seperately and also together?


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## abckidsmom (Aug 24, 2010)

MrBrown said:


> Lets look at this in a macro-level sense;
> 
> 1.  This patient has neurological defecit



Femoral nerve impingment?  Necrosis?  Abcess?



> 2.  Assuming his condition did not change between when the last set of obs were taken and when he died; he said he was feeling hot and cold andwas recorded as being tachycardic.



Sepsis with compensation and then profound failure to compensate?  



> What could these two mean if we consider them seperately and also together?



Together? 

A disc slipped out of place,  causing pressure on those nerves, gradually worsening to necrosis.  Because of the pathogens floating around in his blood stream from his IV drug use, he developed an abcess which slowly built up until he was harboring a huge abcess.  When they gave him the 10 mg of morphine, he felt so great that he moved the wrong way, ruptured the abcess and released all that crap into his system, which killed him over the next 10 hours.


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## lightsandsirens5 (Aug 24, 2010)

Ummmmmm........I dunno. 

Somewhat asymptomatic Spinal Meningitis? In which case the whole b-ball thing is to throw us off.

Slipped disk exerting pressure on the spinal column causing partial paralysis below that point. Inability to urinate eventually caused sepsis, leading to death. (Was there enough time for that?) Of course his body temp is kind of waving me off of the whole septic thing, be it caused by inability to urinate, a burst abscess or whatever. 

Maybe there were some drug incompatibilities in that cocktail of painkillers he was prescribed?

A cerebellar lesion of some kind? Possibly a lesion in the motor cortex or the pyramidal tract thereunto pertaining. :wacko:

Damage to the  lumbosacral plexus. (Although I am not sure ho he did this tripping while playing b-ball. Unless it was cause by swelling in his spinal column actually causing the damage.)

I can't for the life of me figure out how any of those would kill you in a few hours like that though. 

Sheesh Brown..............................


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## abckidsmom (Aug 24, 2010)

lightsandsirens5 said:


> A cerebellar lesion of some kind? Possibly a lesion in the motor cortex or the pyramidal tract thereunto pertaining. :wacko:



A tuberculin lesion, acquired by his shady recreational habits!  And he actually died because he liked the high from the morphine, remembered how great the heroin was, and went out for one last trip that was especially rich.

It hit him so hard all of the sudden, it took him out like a light, and he scraped his arms on the way down, obscuring the puncture from the injection.

Yeah!  I solved it!


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## Jay (Aug 24, 2010)

OK, I think I figured it out. Let's break down some facts and see if we are in agreement:

_Note that before we go on that the one piece of information that is no way realistic here is that this guy actually gets treated expeditiously in the emergency department. Poor treatment but still treatment. Is New Zealand a fantasy land? 
OK, back to the case._
*
I.  The PT was found with two minor skin abrasions on his arms:*
This could be from scratching hard enough to cause the abrasions. However he did trip over and graze his arm which could have caused some kind of trauma perhaps to the site where IV recreational drugs were previously used. If itching was involved it may be because of an increased level of opiates in his system as well. This is a nice way to confuse us but doesn't shed enough light on the why's and what's. Let's go on...
*
II.  3:00 PM Vitals Suggest:*
Possible compensatory septic shock (early stages) however my biggest question is 9/10 pain where??? This was not stated. The difficulty standing was caused by the radicular pain secondary to the spinal nerve root impingement somewhere between L3 and S1. The nausea was either secondary to the pain or acute early onset septic shock. If there was an issue with this particular nerve root there could also be an issue with the kidneys and/or bowels further indicating sepsis, e.g. PT was unable to urinate as his bladder was affected by the radiculopathy which further caused a rupture and thus a chain reaction of events. We now have enough information to sort of derive some basic conclusions. This may be the wrong path but it does fit and the next set of vitals and events only makes this theory stronger...

*III.  The 3:45pm set of vitals indicates:*
The 3:45pm set of vitals was not a result to the administration of the earlier drugs, e.g. benzos which could in theory possibly cause muscle injury (that could be further aggravating a disc injury) to feel somewhat better rather at this point the shock has peaked and is the PT is decompinsating. This would suggest that there was a rupture, e.g. kidney, bladder, etc. that the PT was initially unable to feel. The rupture caused the sepsis and was a result of the radiculopathy which was a direct result of the left sided nerve root impingement which was a direct result of the initial injury which could have caused a partial disc injury to get worse, e.g. torn thecal sac and rupture causing severe impingement where the initial impingement was only mild.

*IV.  The 4:10pm evaluation*:
This would further support my theory of a urological defect secondary to the radicular injury somewhere in the realm of L3-L4, L4-L5 and/or L5-S1. The neuro and urological issues are connected as this is the common denominator.

*V.  Finally:* 
The hot/cold sensations seemed to resolve secondary to the MSO4/drug cocktail; the pain was still there however the pain was being treated yet the underlying factors were not, by this point it was far too late as septic shock has ensured that this poor fellow was already dead.

*Final DX*
1.  Sciatica
2.  Ruptured thecal sac; severe left-sided nerve root impingement to L3-L4, L4-L5 and/or L5-S1
3. Radiculopathy 
4.  Kidney and/or bladder rupture secondary to the impingement above
5.  Sepsis


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## firetender (Aug 24, 2010)

MrBrown said:


> You are called to a house for an unresponsive male.  Upon arrival your assessment reveals the patient has died.  There is no obvious physical signs of traumatic injury apart from one or two minor skin abrasions on his arms....So, what was wrong with this fellow?



He's dead. I go home. Is Coroner's problem. The knowledge of what did or didn't happen with this case would have little bearing on future cases because any intervention would be last minute, circle the drain stuff with no expected change in outcome.


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## medic417 (Aug 24, 2010)

Looks like a scenario right out of the book.  HMMM has brown plagiarized?


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## Veneficus (Aug 24, 2010)

Shouldn't there be some physical exam findings?

Could be a couple of things, 

traumatically ruptured kidney,

acetaminophen OD, 

rheumatic fever from IV drug use. (both heart and kidney)

Nephritis from IV drug use.

Fever suggests nsaid OD. But usually with ASA not tylenol.

Liver failure from hep B/C with acetaminophen and IV drugs.

Bleed from ruptured artery secondary to some vascular degeneration like a polyarteritis nordosa. 

cardiogenic shock from various heart abnormalities/pathologies


There are also a couple of left field pathologies i am too lazy to list. Sounds like a lot of providers dropped the ball though. Back pain, like abd pain, needs to be explored before DC.


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## thatJeffguy (Aug 24, 2010)

This interests me.

I'm a fan of the (already discounted) theories of a spinal bleed or a slow retro-peritoneal bleed.

Other than that I'll revert to my 110hrs of training, give oxygen (15lpm of course) and go to the hospital where the doctor people exist. 

I'll pray that an actual doctor sees the patient as well, of course.


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## MrBrown (Aug 24, 2010)

Hey shut up a House Officer *is* a Doctor even tho none of the patients, nurses, Registrars and Consultants think so 

It's not cardiovascular or renal nor it is stolen from a textbook.


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## lightsandsirens5 (Aug 24, 2010)

MrBrown said:


> Hey shut up a House Officer *is* a Doctor even tho none of the patients, nurses, Registrars and Consultants think so
> 
> It's not cardiovascular or renal nor it is stolen from a textbook.



So are any of mine anywhere close?


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## MrBrown (Aug 25, 2010)

Veneficus said:


> Shouldn't there be some physical exam findings?



of what? 



lightsandsirens5 said:


> So are any of mine anywhere close?



Sort of.


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## Melclin (Aug 25, 2010)

medic417 said:


> Looks like a scenario right out of the book.  HMMM has brown plagiarized?



Sounds like a case study from clinical support reminding you how not to **** up.


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## MrBrown (Aug 25, 2010)

Melclin said:


> Sounds like a case study from clinical support reminding you how not to **** up.



Yeah pretty much.


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## firecoins (Aug 25, 2010)

He died from the flu which he got as a result of a plane crash.


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## chokipokilo (Aug 25, 2010)

MrBrown;244446- At 4.10pm a second year House Officer (Doctor with two years of post medical school training who is not a specalist trainee) examined the patient.  She noted that his complaints were sore back said:
			
		

> How long as the infrequent/inability to urinate been going on?  Is it new tonight or getting increasingly worse over the last week.  Do we know any other problems over the last week aside from pain?


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## lightsandsirens5 (Aug 25, 2010)

MrBrown said:


> of what?


Yea. He's dead.  





> Sort of.



Which ones......


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## MrBrown (Aug 27, 2010)

lightsandsirens5 said:


> Somewhat asymptomatic Spinal Meningitis? In which case the whole b-ball thing is to throw us off.



Nope



lightsandsirens5 said:


> A cerebellar lesion of some kind? Possibly a lesion in the motor cortex or the pyramidal tract thereunto pertaining. :wacko:



Nope



lightsandsirens5 said:


> Damage to the  lumbosacral plexus. (Although I am not sure ho he did this tripping while playing b-ball. Unless it was cause by swelling in his spinal column actually causing the damage.)



Nope



lightsandsirens5 said:


> Slipped disk exerting pressure on the spinal column causing partial paralysis below that point. Inability to urinate eventually caused sepsis, leading to death. (Was there enough time for that?) Of course his body temp is kind of waving me off of the whole septic thing, be it caused by inability to urinate, a burst abscess or whatever.



Yup .... it was a burst spinal absess


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## Aidey (Aug 28, 2010)

The disease process I guessed was dead on then...just the wrong fluid was leaking, lol. I was starting to wonder since his presentation is nearly dead on for increased spinal pressure.


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## MasterIntubator (Aug 28, 2010)

firecoins said:


> He died from the flu which he got as a result of a plane crash.



LOL :lol:


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## Leonidas1 (Aug 28, 2010)

Tetanus poisoning.


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## firetender (Aug 28, 2010)

MrBrown said:


> You are called to a house for an unresponsive male.  Upon arrival your assessment reveals the patient has died.  There is no obvious physical signs of traumatic injury apart from one or two minor skin abrasions on his arms.
> 
> So, what was wrong with this fellow?



So, now that we know, MrBrown, what possible field treatment could be done -- even if the medics showed up 24 hours earlier -- other than transport to the hospital? Where is the applicability to our real world?

(I'm not against the exploration here: even I learned something! but let's bring it home and apply it to action, which, theoretically anyway, is what we're about!)


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## abckidsmom (Aug 28, 2010)

firetender said:


> So, now that we know, MrBrown, what possible field treatment could be done -- even if the medics showed up 24 hours earlier -- other than transport to the hospital? Where is the applicability to our real world?
> 
> (I'm not against the exploration here: even I learned something! but let's bring it home and apply it to action, which, theoretically anyway, is what we're about!)



I'm not brown, but I think that the best and most useful thing in a situation like this is to identify the potential problem, and clearly state your suspicions to the receiving staff.  

There's no way of predicting the fulminant sepsis, but having access is a good thing in case of circulatory collapse. 

I think that the best medics identify a potential problem and make sure that the patient gets to the hospital with the best chance of fixing the problem.  A lot of the "closest, most appropriate hospital" stuff that I deal with in our rural county has to do with people not wanting to drive the extra 25 minutes round trip to the better hospitals (university medical center vs. community hospital).  Plenty of the providers here would have been happy to take this guy to the community hospital with the initial complaints, even though he had plenty of symptoms of needing the more capable medical center.

My .02.  Scenarios of this complexity are fun to think about, and even more fun when they lead to you making a good catch with a real patient.


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## MrBrown (Aug 28, 2010)

Pretty much, the more you know doesn't mean you are less useful because you are unable to do something about it but the opposite; you are more useful coz you can pass it on to the recieving hospital staff.

I have another one of these which I will post up soon.


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## jjesusfreak01 (Aug 28, 2010)

Think about it this way...

If the hospital takes in the patient with no detailed report on a complicated patient and they lose the patient, oh well, they tried.

If the hospital takes in the patient and you told them what you thought was wrong with the patient and they ignore what you said and the patient dies, they are idiots and the hospital better hope your run report doesn't list your speculation or they're toast...j/k my point is the more people that offer input as to possible conditions, the better chance that someone will be right!


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## Jay (Aug 29, 2010)

Brown... Did you see my post on Page 2? Did I nail it or what? 
_
Please note that "or what" is not a valid and/or viable option._

Many thanks!


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