Chief Complaint: Thanksgiving
[ Please note that these accounts do not represent real patients or medical recommendations. Any resemblances are purely coincidental. ]
Time of Consult: 11/24/11 1527
Chief Complaint: not recognizing family members, emotional outbursts, ? Seizure
HPI: The patient is a 19 year old left-handed man who presents with acute, brief episodes of altered mentation. During the past two days while at home with his family, he has appeared to his family members to be more withdrawn, moody, and irritable. He has frequently made statements such as “I hate family gatherings” and “I hate Thanksgiving” and “This totally blows.” When his Aunt Mildred tried to give him a hug, he squirmed and cried out as though in pain. During the five hours of family photographs yesterday, he was thought to have alternating left and right face twitching to which he explained to his father who confronted him that he couldn’t stop the twitching. He has appeared more agitated this morning prior to Thanksgiving dinner. One hour prior to dinner, he walked into a room filled with arriving relatives and family friends, stopped short, stared with a terrified look for several seconds, and then stated loudly, “Who are these people?” Five minutes later, when Aunt Mildred called it upon herself to retrieve him to socialize with the extended family, he was found in his room, “flopping on his bed like a fish out of water.” Aunt Mildred called for help, and her husband, Uncle Ray, thinking that the young man was possessed, attempted to exorcise him. Finding this ineffective in calming his fit, EMS was called and brought the patient to our ED. Neurology was invited to evaluate for the possibility of seizure.
On further questioning with the patient in isolation from his family, he admits that he is very stressed and does not want to spend Thanksgiving with his extended family. He recalls the entirety of the previous events and did not have any impairment of consciousness. There was no tongue biting or lip lacerations. There was no bowel or bladder incontinence. He has no history of seizures. He denies ever having had olfactory or gustatory hallucinations, tableau/deja vu sensations, out of body sensations, or macropsia/micropsia/visual distortion.
PMH: None
Examination: Unarousable to sternal rub and nailbed pressure when family members are by the bedside. Spontaneously open eyes, alert, oriented when the family members are outside the room. No tongue or lip lacerations. No neurologic deficits.
Urine toxicology negative, serum toxicology negative
Assessment: 19yoM with episodes of full body movements and emotional outbursts in the setting of being in a stressful environment, most likely representing an acute stress reaction and possibly malingering. The patient’s presentation is less likely representative of seizure.
Recommendations:
- Consider a social work consult to help offer the patient coping mechanisms for his current predicament.
- The patient may followup in Neurology Urgent Care.
Thank you for this interesting consult.
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Time of Consult: 11/24/11 2150
Chief Complaint: altered mental status
HPI: The patient is a 52 year old right-handed woman who presents with an acute change in her level of consciousness. She was celebrating the Thanksgiving holiday with several family friends when after the sixth course she stood up and announced quietly to her husband, “I have a little bit of a headache. I’m going to go lie down for a minute.” She walked into the living room at approximately 1950 and was not seen by the other members of the party for at least twenty minutes. At 2010, when the dessert course was being passed around, the patient’s husband went to retrieve her and found her slumped over on the couch. Thinking that it would be very impolite to miss out on the rest of the social occasion, he made several vigorous attempts to arouse her, including splashing water on her face and performing a sternal rub. When none of these measures worked, EMS was called. When they arrived on the scene, they took a fingerstick glucose which was 632. She as brought to our ED for further evaluation. A noncontrast head CT was performed in the setting of headache. Neurology was invited to evaluate the patient for altered mental status.
PMH: Diabetes mellitus
Examination: Lethargic but oriented and rapidly recovering after receiving 20 units of insulin and intravenous normal saline. No neurologic deficits.
Noncontrast Head CT: no abnormalities
Assessment: 52yoW h/o diabetes with severe hyperglycemia in the setting of a very large meal.
Recommendations:
- Please advise the patient, who is a diabetic, to mind her portion sizes, especially around holiday meals such as Thanksgiving. Please advise her to continue to taking her insulin as prescribed.
- The patient may followup in the Neurology Urgent Care clinic.
Thank you for this interesting consult on this day of giving thanks.
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Chief Complaint: slurred speech, bilateral arm numbness, Code Stroke
Time Code Stroke Called: 11/24/11 2357
Time of Neurology Evaluation: 11/24/11 2359
Last Seen Normal: 11/24/11 2030
Intravenous tPA administered? – No
Reason if not administered – Seriously?
I was present at the time the head CT was performed and would have reviewed the images within 20 minutes of the patient’s arrival had the patient not urinated in the CT scanner.
HPI: The patient is a 45 year old right-handed man who presents with slurred speech and bilateral arm numbness. He was at a bar with two fellow bachelors passing the time on the evening of Thanksgiving. He arrived at the bar at approximately 2030 after which he proceeded to drink significant amounts of alcohol. He was nursing a bottle of whiskey in his left hand and a shot glass in the right hand with his elbows pressing up against the bar. He was sitting in this position at the bar for about three hours. When he downed the last shot, he said to his friends, “Hey, I can’t feel my arms;” at least, that’s what they thought he said. His speech was thick and barely comprehensible. One friend laughed at him (and he laughed along), but the other was more concerned and called EMS. He was brought to our ED for further evaluation and was triaged as a Code Stroke.
Of note, the patient’s review of systems is significant for anxiety and recent stressors including his wife leaving him, his dog dying, and his truck breaking down.
PMH: None significant.
Social History: Musician.
Examination: Strong odor of ethanol. Awake but inattentive. Disinhibited. Paresthesias along the lateral aspects of both arms from the elbows to the fourth and fifth digits. Bilateral arm and leg ataxia. Unstable gait.
Serum Alcohol level: 376
Assessment: 45yoM p/w slurred speech from alcohol intoxication and bilateral sensory disturbances from ulnar nerve compression.
Recommendations:
- The patient’s slurred speech should resolve once he sobers from his alcohol intoxication. His arm numbness/paresthesias will likely resolve with time as well; he should avoid maintaining the aforementioned position for prolonged periods of time.
- The patient may followup in the Neurology Urgent Care clinic… if absolutely necessary.
Thank you. No really. Thank you.
Happy Thanksgiving!
