Continuing a series on how to make the oral boards more reflective of actual practice.
Examiner: Hello, Dr. 10/10, please have a seat. Your next patient is an 87 year old white female with altered mental status.
Me: I walk in the room and what do I see?
Examiner: You see a thin frail woman staring absently at the ceiling. Her mouth is open in the shape of an “O.” You note that she is moaning incessantly.
Me: Vital signs please?
Examiner: Blood pressure 165/85. Pulse 82. Respirations 16. Temperature 98.9. Pulse ox 95% on room air.
Me: Hello, ma’am, what brings you to the emergency department?
Examiner: Uuuuunnnnnnnh!
Me: What’s your name?
Examiner: Uuuuunnnnnnnh!
Me: Do you know where you are right now?
Examiner: Uuuuunnnnnnnh!
Me: Hmm, nurse do you know anything about this patient?
Examiner: Yes, she was transferred from Cain-Walker Skilled Nursing Facility and Retirement Village because of altered mental status.
Me: You don’t say. How’s she different?
Examiner: It just says altered mental status.
Me: Excellent. What else do we know?
Examiner: Here’s the MAR and some past medical history. We tried calling family but no answer. Oh and she’s listed as a full code.
Me: Perfect. Can I get a nurse from the nursing home on the phone?
Examiner: (Ring) Hello this is her nurse.
Me: Hi it’s Dr. 10/10. This is your patient?
Examiner: Well I’m agency so this is the first night I’ve had her.
Me: I see. Why was she sent here?
Examiner: Oh I don’t know, that was day shift. I just got here.
Me: Do you have any documentation there as to why?
Examiner: Let me see here…(shuffling papers)…it says “altered mental status.”
Me: Great thanks so much. (Click)
Me: Let me look through some of this paperwork here…
Me: Medical history includes Alzheimer’s dementia, multi-infarct dementia, two strokes, a heart attack, angina, mitral valve prolapse, hypertension, hyperlipidemia, diabetes, emphysema, congestive heart failure, atrial fibrillation, hypothyroidism, reflux, dysphagia, osteoarthritis, osteoporosis, peripheral vascular disease, venous insufficiency, macular degeneration, pulmonary fibrosis, and depression.
Me: Meds include aspirin, atenolol, lisinopril, simvastatin, nitro, metformin, glipizide, rosiglitazone, albuterol nebulizer, advair, singulair, lasix, spironolactone, potassium, coumadin, digoxin, cardizem, synthroid, protonix, reglan, phenergan, celebrex, darvocet, hydrocodone, oxycodone, risperidal, seroquel, zoloft, lexapro, paxil, ambien, colace, milk of magnesia, fleets enema, artifical tears, magic mouthwash, nystatin drops, and a multivitamin.
Examiner: The nurse points out that six patients have checked in through triage in the interim.
Me: All right all right, let me proceed with the physical exam.
Examiner: The head is atraumatic and normocephalic. Pupils are 3mm and reactive bilaterally. Arcus senilis is present bilaterally. Extraocular movements appear to be intact. Tympanic membranes are occluded with cerumen bilaterally. Nares patent. Oropharynx reveals upper and lower dentures. The mucus membranes are fairly dry. No obstruction noted. Neck is supple. No lymphadenopathy. Old carotid endarterectomy scars present bilaterally. No bruits. No thyromegaly. No lymphadenopathy. Chest reveals equal breath sounds bilaterally. Rhonchi present throughout. No wheezing. No rales. Cardiovascular exam reveals an normal rate but irregular rhythm. A 2/6 systolic murmur is present as is an S3. No rubs or gallops. Inspection of the abdomen reveals a well healed cholecystecomy scar. It is soft and nondistended. Mild diffuse tenderness is questionably present throughout. No rebound tenderness or guarding. Bowel sounds are present but diminished. Extremities show trace edema to the knees. Changes consistent with venous insufficiency are present. No unilateral swelling. No cellulitis. Grade 1 decubitus ulcers are present on both heels and the sacrum. Skin is warm and dry. Rectal exam shows diminished tone and brown stool which is trace positive for blood. Neuro exam reveals a patient alert but oriented x 0. She localizes to pain and moves all four extremities spontaneously.
Me: Nurse can you bring me a second order sheet? Great. We’ll need the following: a CBC, electrolytes, BUN, creatinine, glucose, LFTs, lipase, coags, cardiac enzymes, digoxin level, TSH, free T4, urinalysis, chest xray, ekg, and a cat scan of the head. In the meantime we’ll water her give her a 500cc normal saline bolus.
Examiner: EKG shows a wide complex irregular rhythm at 80 beats per minute. There are no significant changes from prior EKG’s
Examiner: Chest xray shows a tortuous aorta and flattened diaphragms, as well as a stable nodule. No infiltrates, and no significant changes from previous chest xrays.
Examiner: CT of the brain shows atrophy and multiple lacunar infarcts, but get this no significant changes from previous CT’s. The radiologist does point out that if evolving ischemia is a concern the patient would be best served by MRI.
Me: Noted. Blood work?
Examiner: CBC shows mild anemia, unchanged from previous visits. No white count. Mild hyponatremia is present, again unchanged. Baseline chronic renal insufficiency remains. Unremarkable LFT’s, lipase, and coags. Cardiac enzymes negative. Digoxin and thyroid levels within normal limits.
Me: (Shaking with antipication) And the urine?
Examiner: An infection is present. Positive nitrites, 10-30 WBC’s, many bacteria with few epithelial cells.
Me: (Hands in the air) Yipee!
Me: Nurse, please give this patient 500mg of IV levaquin. I’ll write her a prescription for one weeks worth, and we’ll need to call the ambulance to transfer her back to Cain-Walker.
Me: Let me see how she’s doing after the fluid.
Examiner: (Louder) Uuuuunnnnnnnh!
Me: Outstanding.
Examiner: This concludes your case.
October 11, 2007 at 3:19 pm
Have you been following me around?
“Me: Let me see how she’s doing after the fluid.
Examiner: (Louder) Uuuuunnnnnnnh!
Me: Outstanding.”
Seriously, great series. V. funny.
October 11, 2007 at 4:20 pm
And that, ladies and gentlemen, is why health care costs so much in America.
October 11, 2007 at 5:10 pm
Stellar!
October 11, 2007 at 6:35 pm
I thought the peds case was the best (“I don’t know why I came!” “Neither do I.”), but this one takes the cake! So perfectly dead on!!! The meds, the workup, the moaning, and the nurse who knows only “altered mental status” and “oh, that’s day shift…”!!!
October 11, 2007 at 6:52 pm
I think you have a real future with the ABEM. They clearly need writers who understand the intricacies of the practice of modern day medicine.
October 11, 2007 at 7:07 pm
Wait – this patient somehow has been cloned – I have 3 of them on my census right now! Amazing!
October 11, 2007 at 7:22 pm
One of these days, the nursing homes of the world will figure out how to, ya know, straight cath for a UA and like utilize the near-magical power of the dipstick for 25 cents and figure out if the patient has a UTI. I’ll PERSONALLY go to nursing homes to train staff to DIP suspicious urine and enter the value that corresponds to a color on a form and compare it to normal values.
celebrex, darvocet, hydrocodone, oxycodone, risperidal, seroquel, zoloft, lexapro, paxil, ambien,
*snort*
Me: Let me see how she’s doing after the fluid.
Examiner: (Louder) Uuuuunnnnnnnh!
Me: Outstanding.
That, my friends, is why I bother to read blogs.
April 28, 2009 at 8:44 am
It is the Doctors who usually give the order to send someone to the ER. Nursing homes have to deal with enough liability as it is. It would be irresponsible to try and diagnose someone in a nursing home where there are hardly any resources to do so.
September 1, 2009 at 10:10 pm
Nurse K, Keep complaining about idiot nursing homes ’cause we’re darn sure going to keep complaining about getting our people back with new holes in their butts. How hard is it to turn a patient?
October 9, 2009 at 8:24 pm
How hard it is it to turn a pt?? In the ER??? Pretty damn hard, duh-huh! Let’s see- NsgHm Pt has tons of family, cunningly abiding by the ER policy of no more then two visitors by ‘rotating’, resulting in a constant stream of people back and forth through the ER halls- which happen to be full of patients. The front desk is overwhelmed and no longer cares to even try to moderate. Security is tied up w/ the DT pt. None of said family can hold a cup of water so pt can have a drink, adjust the pillow, or talk to pt while pt is confused and scared. But you know this already- and passed the problem on. Call the nurse.
Meanwhile, 3 nurses and one doctor are taking care of one head bleed, one STEMI, and several not-emergencies yet but will be soon, plus everyone who though the ER would be faster then the MD office. Your Nsg home doc has already called, updating us that after umpteenth call from your facility he had no choice. Even though you have RN’s, you are unable to start an IV and adminster ABX for obvious UTI. Nsg Supervisor cannot help w/ pts, because supervisor is too busy being reamed out by the family reunion your pt’s family is having in our lobby. And since someone is complaining, other pts and their families are forming a line.
Meanwhile, I have provided mouth care to your pt, please tell me- how hard is that to do? I’ve been a CNA, and this mouth has taken days to get to this point. Plus, I’ve had to re-insert the foley your staff placed over a month ago, because it has so much vegeataion in the line we can’t tell if there is truly no output or if it’s simply occluded by a micro lab professor’s dream sample. Ah-ha…. it seems both are the case. It took two other people to help hold your pt’s grossly edematous legs up while divine intervention helped me to cath the bladder, not the vagina. How hard is it to offer water to your residents??? And give lasix AS ORDERED?? After all- all the psych and pain meds- ie shut this pt the hell up meds- were given in a timely manner. Wow, those are all PO meds, yet you cannot give the life-sustaining PO meds D/T AMS. And don’t get me started on the lack of a duoderm on the stage 2 coccyx.
Meanwhile, I have provided pericare multiple times and aforementioned douderm (I had the RT tech raid the Med-Surg floor supply- he should have clocked out 90 minutes ago), linen multiple times, IV times one attempt, took 15 minutes alone to removed the hard scaley stool, and while documenting multiple bedsores, I left out the red area on your pt’s R. buttock that you are now blaming on us. Oh, and the chopperSSSSS are on their way to pick up STEMI and head bleed. The kid w/ RSV has resp of 60. The other kid with strep is stridorous, and I’m listening to the family reunion smash you.
Unfortunatly, I actually tried to defend you. Sad to say, a week later, pt was A&O as best possible, hydrated, clear lungs, no edema, bedsores improving, clean urine AND foley line, and smiling, only to be sent back to you so that we can repeat whole process ad nauseum next month. I guess pt is lucky to have insurance good enough to ’save her spot’ at your stellar facility!
October 12, 2007 at 5:22 am
ROTFLOL Such a perfect description of way too many of my patients. But you left out the lipase; that’s our ER’s favorite. After all, who knows, even with no abdominal symptoms, it might be mesenteric ischemia.
October 12, 2007 at 6:07 pm
Hahahahaha! The “shaking with anticipation” part got me!
So what was this test for?
October 14, 2007 at 1:57 pm
[...] par semaine à l’hôpital, tous ceux qui sont en médecine, allez donc lire ça: What’s Warm, Wet, and Costs $10,000 to Diagnose. Trop drôle, et hélas presque réaliste même au [...]
October 14, 2007 at 10:23 pm
http://www.soundclick.com/bands/Lyrics.cfm?BandID=359619&songid=2806800
October 14, 2007 at 10:24 pm
Urosepsis song. Doctor D is an ER doc in Texas. He’s an awesome musciain.
October 15, 2007 at 6:53 am
*claps* Do write more of these!
October 16, 2007 at 11:04 am
oh my god, that’s hilarious!! i’ll see you in chicago this weekend!! don’t forget to ask ‘what do i see, hear and smell as i walk in the room.’ sometimes those additional clues come in handy (or so i hear). looks like you’re ready for the test. good luck.
October 17, 2007 at 9:09 pm
I saw that same patient today. Actually there were ten of them.
This folks is going to bankrupt the country.
October 18, 2007 at 5:06 am
That was great. Nursing homes rule, good luck on your oral boards.
PS don’t forget to wash your hands and face upon entering each mock patient room
November 10, 2007 at 2:14 pm
The Children of this lady are all probably doctors, attorneys, professors, BSN’s, or pharmacists who are too busy or tired and possibly self-absorbed in their own lives. So when the nursing home calls everyone in the house recognises the caller ID number and patients like this come in alone and leave alone. But everyone is sure to be at the funeral arguing over who did the most to take care of mom.
May 9, 2008 at 8:56 am
Maybe here is the problem: Meds include aspirin, atenolol, lisinopril, simvastatin, nitro, metformin, glipizide, rosiglitazone, albuterol nebulizer, advair, singulair, lasix, spironolactone, potassium, coumadin, digoxin, cardizem, synthroid, protonix, reglan, phenergan, celebrex, darvocet, hydrocodone, oxycodone, risperidal, seroquel, zoloft, lexapro, paxil, ambien, colace, milk of magnesia, fleets enema, artifical tears, magic mouthwash, nystatin drops, and a multivitamin.
Take her off 90-100% of them and watch her live again!!! Just a thot.
July 29, 2008 at 3:54 pm
LOL! Okay, I’m NOT a doctor, but i enjoyed it just the same. Your sense of humor is pretty…er… humorous.
Great post.
P.S. I hope you know your current post is featured on wordpress in the log-in page. Congrats
August 29, 2008 at 12:06 pm
I often work nursing seniors and it has almost always been my experience that when a senior develops altered mental status without any obvious trauma, the first thing we do is dip their urine. UTI in seniors = altered mental status.
In Canada it is a nurse’s judgment call to dip urine. It likely is in the US as well. if not, it should be. Most often the senior never has to be transfered to emergency. If the chem strip is positive we then contact doc on call for a med order.
If a senior does present to ER with altered mental status usually the first thing we do is dip.
September 6, 2009 at 2:45 pm
Nursing home’s didn’t use to dip urine and I doubt they do any more. They have taken everything out of the nurses hands and we have to have orders for everything. But we also get tons of these patients in the ICU, love the urosepsis on the 80 yr old stroke, dementia, being fed through a peg and FULL CODE. Or codes and we get them, Im still wondering how the nsg home did CPR or maybe WHY the nsg home did CPR this is why America is broke and spending so much on health care. When you are that old, don’t know you are in the world what quality of life do you have??? We need to educate people on quality of life over quantity!
April 19, 2009 at 5:41 pm
Очень полезно
April 27, 2009 at 8:12 pm
I think I’ve brought this patient to the ED before
May 28, 2009 at 6:22 pm
I had this patient today, but she had a dvt and a uti and got admitted.
November 17, 2009 at 4:27 am
I am in another country and I see this patient as well – most days – and her numerous sisters.
often as a friday evening nursing home dump
no wonder the ward is typically full
November 26, 2009 at 8:42 pm
In response to WhatTheHellRN—I applaud you! That was perfect!!!
Truthfully, the original post was pretty amazing on its own. I love it! Very well done.