In any particular shift, there is a chance you will get to see a patient which an ‘unusual’ or downright weird presentation. Often it is a perception problem on the part of the patient, and usually things are amenable to reassurance and counselling. This particular shift was ‘unusual’ for a number of reasons: the sheer number of ‘unusual’ presentations packed into a single shift, and the distinct lack of faith in my *ahem* reassurances.
Case in point A – 28 year old female walks in to the department with sensation of a foreign body stuck in her throat. Fair enough, seems legit. She then proceeded to tell me how she had had some bacon last night (yes, more than 12 hours back) and she felt that it was too hard, and very chewy and when she swallowed it she felt as though it had gotten stuck somewhere in her throat (so many questions, like why did you eat it if it was so hard and chewy and difficult to swallow and how big of a bite did you take? but of course what I really asked her was…). Have you eaten or drunk anything since then and she said oh yeah, I have had some toast this morning, and have been trying to drink lots of water to wash it down with. Any vomiting? No. Any chest or abdominal pain? No. Any previous history of having things stuck in your food pipe when you swallow? NO. OK, so what do are your actual symptoms? Well I felt all night as if this was stuck in my throat somewhere, and so I am having difficulty swallowing and also I think I am choking on it because I am finding it difficult to breathe. To which I had to explain to her the concept of the two different pipes, one for the airway and a separate one for swallowing food and drink. I asked her if she had had a cough at all, to which she replied in the negative. I tried to reassure her that had anything gone down the wrong pipe she would not have been sitting here comfortably talking to me the next day, she would be quite distressed and, quite frankly – choking! She just stared at me as if I didn’t know what I was talking about. Anyway, needless to say, she didn’t buy my reassurances, and said she wanted me to look down her throat and pull it out. I tried convincing her that everything seemed to be clinically alright and there seemed to be no indication of anything stuck anywhere (except me in this situation!) but she was having none of it. I excused myself, and discussed it with my consultant, who agreed there didn’t seem to be any indication for further assessment, but advised me to speak to ENT, and whatever they say I could use to reassure the patient. I spoke to ENT who very kindly understood my predicament and volunteered to come down and speak to the patient themselves. They were also of the opinion that there was nothing in her throat that should not have been there, but they offered to scope her, and guess what they found?
Yup. That’s right. No foreign body in her throat. And she very happily went home after that.
My next patient was by far the 2nd most bizarre occurrence of the day. Young 30 something male, walked into the department with an ‘unusual’ complaint. More of a request. He was known to have a hydrocele (a collection of fluid in the lining of the testicle, correctible with a small surgical procedure), and was waiting for an appointment for it to be surgically corrected. He missed his appointment for surgery for whatever reasons, and – get this! – he thought he would come in to ED to, and I quote: ‘Get it sorted today.’ *unquote*
I asked him if the condition had changed in any way or he had any new symptoms. No. Any fever or discharge? No. Any pain? a discomfort, yes but no actual pain, the discomfort had been going on for months now. Any abdominal pain? No. Any problems passing urine? No.
Well then I asked him quite frankly why he had come in to ED today? And he explained to me that he didn’t come in to hospital for himself today. His wife was in labour and he was just waiting to hear the good news, so he thought while he was waiting, he could pop in to ED to ‘get it sorted’. I explained to him that A) this wasn’t a case for the ED; B) I couldn’t give him an appointment for surgery even if I tried; C) did he think this was like a McDonald’s drive-thru? walk in to the ED, get an invasive surgical procedure done, walk right out? I examined him and assessed him fully, but I wasted no time in letting him know that the A&E was for exactly what it stands for: Accident and/or Emergency. I referred him back to his GP to sort out the appointment for him, possibly after his wife’s delivery. And I tried very hard not to blog about it then and there!
My third case (like I said, it was a series of bizarres, I kept waiting for someone to say ‘surprise! you’re on candid camera!) was that of an older female, in her late 50s, early 60s – who came in with a 9 week history of headache. Yes, NINE weeks. Gradually worsening, associated for the past 1 week with worsening neck pain and for the past 3 days with dizziness, nausea and vomiting, and that evening, she had gotten up off the toilet, felt very dizzy, walked out into her living area, and proceeded to lose consciousness for 10 whole minutes, unwitnessed but found by her husband who was in the next room and heard her fall. She now complained of feeling her legs were weak and numb, and that she couldn’t moved her lower limbs of her own accord at all. She denied any back pain, there were no obvious signs of a head injury, and her sensations and power seemed to be intact, though generally weak in all muscle groups and not just the legs. Very non specific, but I discussed with my registrar the need for CT scan of her head. Oh, and she said she was worried because her mother had passed away at a young age due to a brain tumor. My registrar was reluctant to approve the CT head, but I suggested since I will document that this was long standing headaches, with sudden worsening, associated with loss of consciousness and some degree of neurological findings (however subjective they might be) that it would warrant a scan. It was then approved, and we got the CT scan sorted, trying to rule out a brain bleed. The scan was done, looked grossly normal, and per the medical guidelines, since a normal CT scan did not rule out a bleed completely, we admitted her under the medical specialty for observation and a lumbar puncture, which would check the fluid around the brain and spinal cord for evidence of the bleed, should there have been any. After the scan, as I explained all this to the patient, she became a bit nervous and looked visibly anxious at the prospect of a needle in her spine to extract fluid.
And as I stepped out of the cubicle and moved on to my next patient, I saw that, lo and behold, her lower leg weakness was miraculously cured as she got out of the bed ON HER OWN and then walked out for a cigarette. Sigh. She self-discharged herself after that, and walked out of the A&E on her own two fully recovered and recuperated legs. Fully cured of the headache and no signs of any of the weakness from previous. That wasn’t a waste of resources at all, was it?