Friday, June 02, 2006

Triage Tales 15

Disclaimer: The following story is a work of fiction. All similarities to people, places, things and events are coincidental by nature.

63 year old male, comes in with a complaint of "seizure". Allegedly a Generalized Tonic-Clonic one, for 30 minutes! Amazingly there is no gross neurologic deficit aside from the fact that he has illogical speech patterns.

On further history, patient has been seen at the Pulmonary Outpatient Clinic as well as the Thoracic and Cardiovascular Surgery (TCVS) Outpatient Clinic for a pulmonary mass on the right. Dyspnea on exertion, weight loss, and nonproductive cough round off this picture.

Initially the Triage Officer sought the opinion of the Surgeon On Duty at the ER (SOD). Since the seizure history is a little spotty at best, the Triage Officer looks for a quick disposition. But the SOD, having referred the case to the TCVS, is adamant that without a definitive tissue diagnosis, there is no indication for a surgical admission.

So the ER Officer tells the Triage Officer to deck the patient to her Treatment Officer, and also says that the patient can be referred to the Medicine service after the lab work has been done. Assessment for justification of referral? The "seizure" could have been because of brain mets from a pulmonary mass.

The Medicine resident, after the initial work up, tells the Treatment Officer that in order to refer a patient with seizures, there must be an underlying medical condition that is an identifiable cause.

The Neurology resident is a little sore as she overhears the discussion. She says that she will only accept the patient if there is an identifiable cause for the seizure. She will also not accept an intracranial mass, as these patients go directly to Neurosurgery.

And the labs clear up the diagnosis. Blood Chemistry is normal, Hemoglobin is 69 but it's because of the chronicity of the mass.

CT Scan shows a well-circumscribed, hyperdense lesion about 1-1.5cm in diameter with hypodense halo on the L parietal area.

In the aftermath of everything, (including having the patient transported to an outside facility because the hospital's CT Scan machine has been broken for 4 days straight!) the incoming Medicine resident receives the patient as the mass is a manifestation of a Stage 4 Pulmonary Mass.

Patient is started on Mannitol and Dexamethasone, and remains asymptomatic and without seizure on his eighth hour at the ER. Patient stays for more than 24 hours, naturally, because there is no ward vacancy.

Postscript: I had to edit my original post as it was incomplete. ;D

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