I had a woman brought to me because she couldn’t get off of her toilet.
“Because of a bomb?” I asked but no, instead she was just too weak. Too weak all over. It had actually started about a month ago, and she had fallen then and fell a week ago and fell last night, all because her legs kept giving out on her. And tonight she had managed to plop down on the toilet but when she was done she found that she was just too weak to get up. She called for her husband, who had helped her up all those other times, but this time he couldn’t overcome her weakness, and instead called for an ambulance. The medics came and hoisted her up and saw the toilet bowl full of blood beneath her and shortly thereafter she was a patient in my ER.
So I knew what was wrong before I ever saw her. She was a GI bleed, from hemorrhoids or diverticulosis or cancer or something, and now I’m on autopilot as I scribble out her orders: 2 IV’s, fluids, NG lavage, foley, blood tests.
She looks pretty good, I note, as I walk in the room to meet her. Her heart rate’s slightly up in the 90’s, but her blood pressure is good and her color is good and she looks good — an overweight 70ish female in no apparent distress.
I asked her a few questions while going through a cursory exam. Blood thinners? No. When did the bleeding start? I didn’t know I was until tonight I don’t really look. Have you ever had a colonoscopy before? I think several years ago I don’t remember anything being wrong.
The last part of the exam, the rectal, shows brown stool that is guaiac positive. You’ll need to be admitted to the hospital, I tell her as I’m leaving, and we’ll know more after your tests come back in a couple of hours.
I manage other stuff for awhile and then revisit her, double-clicking next to her name to get the results of her blood tests. A three gram drop in her hemoglobin from a fairly recent visit makes it likely that the blood loss is the cause of her weakness. Electrolytes look ok, kidney function a little worse but to be expected, coags and platelets fine, but I scroll again to the top. A white count of 34,000? What is that all about? Blood cultures are drawn and she gets some antibiotics in antipication of the infection I figure I’ll find in her urine but it comes back normal. And so does her chest xray.
At this point I really just want to call up the hospitalist and admit her. There’s no reason why they can’t take over from here. But I hold off. I’m missing something and I feel compelled to at least talk to her again.
So some new questions. Any fever? No. Symptoms of infection? No. Weight loss? No. I reexamine her, this time with more purpose. When I get to her abdomen it’s tender, especially under her rib cage on both sides. Was it like this before? I don’t think so, but it’s hard to say, it really wasn’t a very good exam. I bite the bullet and decide to CAT scan her, looking for a cholecystitis or perforated peptic ulcer or weird diverticulitis or appendicitis or whatever, knowing that it’ll add at least another two hours to an already lengthy stay.
But it turned out to be the right decision. She had one of the whatevers — a lacerated spleen. Holy crap, I think as I read the faxed report, she busted her freaking spleen when she fell last night. And I’m both fired up and relieved to have found it, and to get her transferred to the local trauma center instead of having her languish on the floor as a misdiagnosed GI bleed.
I feel fortunate to have saved her from myself.
December 21, 2007 at 7:13 am
Great catch!
December 21, 2007 at 8:50 am
I was thinking lacerated spleen from the first line, but then I’m always thinking lacerated spleen.
December 21, 2007 at 12:10 pm
I love that you mentioned the bomb. That movie was awesome!
I also love that you caught what was wrong. That is even more awesome!
Happy holidays!
December 21, 2007 at 12:26 pm
Great job 10/10. I thought of you yesterday. I topped my high score on that damn game, got 2000. Then I messed up typing seeker. Ironic.
December 21, 2007 at 2:39 pm
Wow! It’s great you were able to make the diagnosis. Why does lacerated spleen give such a high white count…I know I should look it up in Tintinalli’s but I am too lazy.
December 21, 2007 at 6:30 pm
Wow, it’s like watching House.
December 22, 2007 at 12:24 pm
Sines — Just speaking from anecdotal experience, significant trauma results in a stress response that will get your white count up, although the magnitude of her leukocytosis was atypical. Luckily for her — if she was around 15,000 or so I doubt I would have ever gone back.
December 22, 2007 at 4:17 pm
It’s been a long time since I took A&P, but I remember the spleen as part of the lymphatic system. How did the blood get from the spleen to the GI tract? A ruptured spleen doesn’t just bleed into the peritoneal cavity?
I did at least know what caused the elevated white count, but spleen to GI tract? Not getting it.
December 22, 2007 at 4:37 pm
Sue — I can see how that’s not clear. We try to tie up all of a patient’s symptoms with one neat diagnosis, but in this case she had two separate problems, some (probably) minor bleeding coming from somewhere in her intestines which almost caused me to miss the real problem, a lacerated spleen bleeding, like you said, not into the GI tract but into the belly.
December 22, 2007 at 5:09 pm
Initially I was thinking she’s got 2 problems, but then you said this- “…a misdiagnosed GI bleed “. Then I though “Man, Ten’s been smokin’ too much crack”. But none of the other commenters asked you about it so I started thinking “WTF?”. I work in a level 1 trauma center. If blood can travel from the spleen to the GI tract this is something I need to know!
Anyway, thanks and great catch!
December 23, 2007 at 12:29 am
Love the Lethal Weapon reference…
December 23, 2007 at 12:32 pm
Wow, great post! As a medical student, I found it an ideal exercise – hard enough that I wouldn’t guess what it was, but easy enough that I could follow it. But what was the white cells count about, was the spleen releasing them or what?
Oh, and I loved the Lethal Weapon line as well
December 25, 2007 at 12:41 am
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November 28, 2008 at 9:39 pm
The method of using certain food combinations in order to control digestive problems has been around for a long time. The problem is that so many people get into the habit of eating their foods in specific combinations that they’ve been using for their entire lives that they can’t seem to break out of those habits even when the solution to their digestive problems is easily within their reach. It has been proven over and over that certain types of foods don’t digest well when mixed with other types of foods because it causes a hostile environment in the gut that often ends up releasing certain toxins into the digestive system. When these toxins are absorbed they cause the breakdown or lysis of different tissues over time. This tissue breakdown results in the various digestive conditions that you hear so much about and that cause so much pain and misery. Some of these conditions include diverticulitis, colitis, irritable bowel syndrome, acid reflux,chronic constipation and diarrhea, not to mention ordinary old indigestion. If people would learn to eat the appropriate food combinations, it would mean that their digestive conditions could improve significantly and they could enjoy life again instead of suffering through the digestive symptoms and taking all those pills, powders and often falsely touted “special foods.” It’s not difficult, it’s just a matter of learning the right food combinations and using them. Life will get better if people can just do this.