A Little Clinical Thinking Needed

[Guest guest]

You are called to the scene of a 47-year-old male who lives alone in

government-subsidized housing. His sister brings him groceries every week.

Today, she noted very bizarre behavior. The patient is happy yet confused.

When you ask his name, he thinks for a while and says " Darwin. " You

ask him how he feels. He says, " I have headache and shoulder pain. " You

respond, " So you have a headache? " he says, " No, I hurt here " (pointing to

his head). You say, " Where do your shoulders hurt? " He says, " My shoulders

don't hurt, it is my shoulders that hurt? " You ask his sister how she found

him. She says, " When I walked in, he said there was a parrot in the closet.

I looked in the closet and there was nothing. " At this time, the patient's

eye's brighten and he says, " Parrot in the closet, parrot in the closet,

parrot in the closet, parrot in the closet. " He walks to the closet door and

opens the closet, looks in, and closes the closet. He does the exact same

thing another 8 times before his sister takes his hand and leads him to the

kitchen table where he sits. You ask him his name again and he says, " Clyde

Barrow. " You ask the date and he says, " December 7, 1978. " You ask him the

name of the President of the United States and he gives you a big smile and

with a feigned southern accent says, " Jimmy -of course " . You tell his

sister he needs to go to the hospital. He perks up and says, " Can we go in

the boat? " He puts on his shoes and starts singing the dirty version of

Barnacle Bill the Sailor?

What else would you like to know?

Diagnosis?

[Guest guest]

An educated guess would be carbon monoxide poisioning (low levels).

Can I have some complete vitals please?

>

>Reply-To: texasems-l

>To: <texasems-l >,<Paramedicine >

>Subject: A Little Clinical Thinking Needed

>Date: Wed, 20 Sep 2006 23:18:07 -0500

>

>You are called to the scene of a 47-year-old male who lives alone in

>government-subsidized housing. His sister brings him groceries every week.

>Today, she noted very bizarre behavior. The patient is happy yet confused.

>When you ask his name, he thinks for a while and says " Darwin. "

>You

>ask him how he feels. He says, " I have headache and shoulder pain. " You

>respond, " So you have a headache? " he says, " No, I hurt here " (pointing to

>his head). You say, " Where do your shoulders hurt? " He says, " My shoulders

>don't hurt, it is my shoulders that hurt? " You ask his sister how she

>found

>him. She says, " When I walked in, he said there was a parrot in the

>closet.

>I looked in the closet and there was nothing. " At this time, the patient's

>eye's brighten and he says, " Parrot in the closet, parrot in the closet,

>parrot in the closet, parrot in the closet. " He walks to the closet door

>and

>opens the closet, looks in, and closes the closet. He does the exact same

>thing another 8 times before his sister takes his hand and leads him to the

>kitchen table where he sits. You ask him his name again and he says,

> " Clyde

>Barrow. " You ask the date and he says, " December 7, 1978. " You ask him the

>name of the President of the United States and he gives you a big smile and

>with a feigned southern accent says, " Jimmy -of course " . You tell his

>sister he needs to go to the hospital. He perks up and says, " Can we go in

>the boat? " He puts on his shoes and starts singing the dirty version of

>Barnacle Bill the Sailor?

>

>

>

>What else would you like to know?

>

>

>

>Diagnosis?

>

>

>

>

[Guest guest]

Dr. Bledsoe,

Horses or zebras here?

What med is he " not " taking?

CSS

[Guest guest]

The obvious things would be:

PMH?

Routine Meds?

Alcohol abuse history?

Illicit drug use history?

Blood sugar reading?

V/S, SpO2, EKG?

LA Stroke Score?

Breath odor?

Dialysis patient?

The not so obvious things would be:

Any drugs or booze around the house?

Gas Furnace?

Any sources of Methanol?

Odors in house?

Until I have more information, I'd be suspicious for:

Hypoglycemia

CVA

Drug OD (illicit or prescription)

Carbon Monoxide poisoning

Ethanol or Methanol ingestion

High urea levels

Until I know more about my patient, I can't give a better diagnosis. He's a

candidate for being tossed on a stretcher and hauled to the closest

appropriate hospital.

Barry E. McClung, EMT-P

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of Bledsoe, DO

Sent: Wednesday, 20 September, 2006 23:18

To: texasems-l ; Paramedicine

Subject: A Little Clinical Thinking Needed

What else would you like to know?

Diagnosis?

[Guest guest]

More Information:

PMHX: The patient has a history of multiple long bone fractures from a

motorcycle accident (MCA). He is ambulatory but with difficulty. He has a

history of hypertension and GERD.

PSHX: Multiple operations for ORIF of multiple long-bone fractures from a

MCA. He has had a Splenectomy secondary to the MCA.

SOCIAL: He is currently unemployed and on Medicare and Medicaid because of

his resultant disability from his MCA. He worked for 22 years as a diener.

He smokes ½ - 1 packs per day of Camel unfliltered cigarettes and has a 23

pack/year history. He drinks beer. He sister says that many years ago he

smoked mushrooms but does not believe he has done that in some time.

PSYCH: He has a history of depression. She knows he has had a few psych

admissions but she does not know the reason or outcome of these.

ENVIRONMENTAL: He had some chemical and biological exposure as a diener. He

has had problems with insects and vermin in his apartment but she does not

know if they sprayed. The apartment is all electric. A quick look in the

medicine cabinet reveals: ASA, ibuprofen (Walgreens’s brand), propoxyphene,

lisinopril, sertraline, Maalox, and milk of magnesia.

HPI: No recent trauma. No known toxic exposure. No fever/chills. Normal

diet (he eats Count Chocula for breakfast every day). No change in

cigarette choice or beer. Neighbors report several UPS and FedEx deliveries.

No parrot. He has a pet cat but she cannot be caught.

_____

[Guest guest]

What was in the Fed Ex and UPS packages?

But the cat is alive, right? Is the cat normally afraid of people? The

sister even?

And BTW......Count Chocula IS toxic.....as I have assured my children

many times!!!

Jules

RE: A Little Clinical Thinking Needed

More Information:

PMHX: The patient has a history of multiple long bone fractures from a

motorcycle accident (MCA). He is ambulatory but with difficulty. He has

a

history of hypertension and GERD.

PSHX: Multiple operations for ORIF of multiple long-bone fractures from

a

MCA. He has had a Splenectomy secondary to the MCA.

SOCIAL: He is currently unemployed and on Medicare and Medicaid because

of

his resultant disability from his MCA. He worked for 22 years as a

diener.

He smokes ½ - 1 packs per day of Camel unfliltered cigarettes and has a

23

pack/year history. He drinks beer. He sister says that many years ago he

smoked mushrooms but does not believe he has done that in some time.

PSYCH: He has a history of depression. She knows he has had a few psych

admissions but she does not know the reason or outcome of these.

ENVIRONMENTAL: He had some chemical and biological exposure as a

diener. He

has had problems with insects and vermin in his apartment but she does

not

know if they sprayed. The apartment is all electric. A quick look in the

medicine cabinet reveals: ASA, ibuprofen (Walgreens’s brand),

propoxyphene,

lisinopril, sertraline, Maalox, and milk of magnesia.

HPI: No recent trauma. No known toxic exposure. No fever/chills. Normal

diet (he eats Count Chocula for breakfast every day). No change in

cigarette choice or beer. Neighbors report several UPS and FedEx

deliveries.

No parrot. He has a pet cat but she cannot be caught.

_____

[Guest guest]

1) Is his wife's name Bonnie ?

2) Any evidence that he has been eating human remains?

3) Does he really have a bird coming around, (histoplamosis?)

4) And the Cat... toxoplasmosis...

4) Probably could check with MHMR, and look at his previous psych admits..

5) Korsakoff's can present with anterograde amnesia and grand confabulation

right?

Interesting, please give us the vitals and labs when they are available..

" Bledsoe, DO " wrote:

You are called to the scene of a 47-year-old male who lives alone in

government-subsidized housing. His sister brings him groceries every week.

Today, she noted very bizarre behavior. The patient is happy yet confused.

When you ask his name, he thinks for a while and says " Darwin. " You

ask him how he feels. He says, " I have headache and shoulder pain. " You

respond, " So you have a headache? " he says, " No, I hurt here " (pointing to

his head). You say, " Where do your shoulders hurt? " He says, " My shoulders

don't hurt, it is my shoulders that hurt? " You ask his sister how she found

him. She says, " When I walked in, he said there was a parrot in the closet.

I looked in the closet and there was nothing. " At this time, the patient's

eye's brighten and he says, " Parrot in the closet, parrot in the closet,

parrot in the closet, parrot in the closet. " He walks to the closet door and

opens the closet, looks in, and closes the closet. He does the exact same

thing another 8 times before his sister takes his hand and leads him to the

kitchen table where he sits. You ask him his name again and he says, " Clyde

Barrow. " You ask the date and he says, " December 7, 1978. " You ask him the

name of the President of the United States and he gives you a big smile and

with a feigned southern accent says, " Jimmy -of course " . You tell his

sister he needs to go to the hospital. He perks up and says, " Can we go in

the boat? " He puts on his shoes and starts singing the dirty version of

Barnacle Bill the Sailor?

What else would you like to know?

Diagnosis?

[Guest guest]

RAM memory is full. Get a bigger chip. I think you just described me on Friday

morning.

Henry

Re: A Little Clinical Thinking Needed

1) Is his wife's name Bonnie ?

2) Any evidence that he has been eating human remains?

3) Does he really have a bird coming around, (histoplamosis?)

4) And the Cat... toxoplasmosis...

4) Probably could check with MHMR, and look at his previous psych admits..

5) Korsakoff's can present with anterograde amnesia and grand confabulation

right?

Interesting, please give us the vitals and labs when they are available..

" Bledsoe, DO " wrote:

You are called to the scene of a 47-year-old male who lives alone in

government-subsidized housing. His sister brings him groceries every week.

Today, she noted very bizarre behavior. The patient is happy yet confused.

When you ask his name, he thinks for a while and says " Darwin. " You

ask him how he feels. He says, " I have headache and shoulder pain. " You

respond, " So you have a headache? " he says, " No, I hurt here " (pointing to

his head). You say, " Where do your shoulders hurt? " He says, " My shoulders

don't hurt, it is my shoulders that hurt? " You ask his sister how she found

him. She says, " When I walked in, he said there was a parrot in the closet.

I looked in the closet and there was nothing. " At this time, the patient's

eye's brighten and he says, " Parrot in the closet, parrot in the closet,

parrot in the closet, parrot in the closet. " He walks to the closet door and

opens the closet, looks in, and closes the closet. He does the exact same

thing another 8 times before his sister takes his hand and leads him to the

kitchen table where he sits. You ask him his name again and he says, " Clyde

Barrow. " You ask the date and he says, " December 7, 1978. " You ask him the

name of the President of the United States and he gives you a big smile and

with a feigned southern accent says, " Jimmy -of course " . You tell his

sister he needs to go to the hospital. He perks up and says, " Can we go in

the boat? " He puts on his shoes and starts singing the dirty version of

Barnacle Bill the Sailor?

What else would you like to know?

Diagnosis?

[Guest guest]

VITALS: BP: 138/90, Pulse: 88, Respirations: 22, Temp: 37.2, SpO2: 99% RA

HEENT: PERRLA, EMOI. Fundi benign. No disc cupping. Immature cataract OD.

VA OD=20/100, OS=20/100, OU 20/100. TMs clear. No EAC discharge. Nose: Boggy

mucosa. Septum midline. Mild pharyngeal erythema. No lesions. Dentition

in fair repair with obvious caries. No cervical lymphoadenopathy. Possible

+1+ 4 carotid bruit right, none left. No thrills. Thyroid midline and not

enlarged. Full cervical ROM.

CHEST: HRRR, Grade I-II/VI holosystolic murmur heart best at left sternal

border. PMI normal. Lungs CTA with scattered faint bilateral wheezes. No

chest lesions. No gynecomastia.

ABD: Soft and non-tender. Midline scar and drainage scars-well healed. Good

BS. No CVA or flank tenderness. Negative Lloyd's Negative 's. No

tenderness at McBurney's point.

GU: Normal uncirc male. Testes down. No masses. No scrotal asymmetry. No

discharge.

RECT: Normal tone. Hemoocult (-). Normal prostate.

EXT: Multiple surgical scars. Pulses OK distally. No nodes.

NEURO: CN II-XII grossly intact. DTRs +2/+4 except right patellar at +1/+4.

No clonus. Normal Webber and Rine. Decreased vibratory sense right lower

extremity. Prorpioception normal. Antalgic gait. No tremor. No ataxia.

MENTAL STATUS: Not oriented to person, place or time. Says he is Al Capone

and this is " Valentine's Day in 1936. Consciousness is episodically cloudy.

Answers are approximate. Patient exhibits preservation, echopraxia and

echolalia. Doesn't recall what he ate for breakfast or lunch. Cannot name

two states that adjoin Tennessee. Thought processes concrete. Intellect

appears low normal. He has multiple somatic complaints but they change with

physical exam. When told that " The leopard killed the lion " , he was asked,

" Who won? " He answered. " The Boston red Sox-but this year only. " When

asked why people who live in glass houses should not throw stones he

answered. " Glass is expensive. " When asked the President of the United

States he says " I like Ike. "

LAB: Tox screen (+) THC

CBC: WNL (except macrocytic anemia)

BMP: Normal except Na+ of 148 mEq/L.

LFTs: Mild elevation ALT, GGT.

MRI of Head: Diffuse mild atrophy. No changes on heavily weighted cuts.

UA: WNL

What now?

[Guest guest]

In a message dated 9/21/2006 7:46:05 AM Central Standard Time,

bbledsoe@... writes:

He worked for 22 years as a diener.

Am I the only one who is willing to admit that they had to google on his job?

among other questions: how long has his vision been bad?

I'm suspecting some serious long term toxic effects, as there is no evidence

of mass effect on either the CT or MRI of the head.

ck

S. Krin, DO FAAFP

[Guest guest]

In a message dated 9/21/2006 6:11:47 PM Central Standard Time,

bbledsoe@... writes:

Decreased vibratory sense right lower

extremity. Prorpioception normal. Antalgic gait. No tremor. No ataxia.

Another question: what about a Serologic Test for Syphilis..preferably with

dilutions...

ck

S. Krin, DO FAAFP

[Guest guest]

This sounds like an exam on Willie ........JK

>

>Reply-To: texasems-l

>To: <texasems-l >,<Paramedicine >

>Subject: RE: A Little Clinical Thinking Needed

>Date: Thu, 21 Sep 2006 18:07:48 -0500

>

>VITALS: BP: 138/90, Pulse: 88, Respirations: 22, Temp: 37.2, SpO2: 99% RA

>HEENT: PERRLA, EMOI. Fundi benign. No disc cupping. Immature cataract OD.

>VA OD=20/100, OS=20/100, OU 20/100. TMs clear. No EAC discharge. Nose:

>Boggy

>mucosa. Septum midline. Mild pharyngeal erythema. No lesions. Dentition

>in fair repair with obvious caries. No cervical lymphoadenopathy. Possible

>+1+ 4 carotid bruit right, none left. No thrills. Thyroid midline and not

>enlarged. Full cervical ROM.

>CHEST: HRRR, Grade I-II/VI holosystolic murmur heart best at left sternal

>border. PMI normal. Lungs CTA with scattered faint bilateral wheezes. No

>chest lesions. No gynecomastia.

>ABD: Soft and non-tender. Midline scar and drainage scars-well healed. Good

>BS. No CVA or flank tenderness. Negative Lloyd's Negative 's. No

>tenderness at McBurney's point.

>GU: Normal uncirc male. Testes down. No masses. No scrotal asymmetry. No

>discharge.

>RECT: Normal tone. Hemoocult (-). Normal prostate.

>EXT: Multiple surgical scars. Pulses OK distally. No nodes.

>NEURO: CN II-XII grossly intact. DTRs +2/+4 except right patellar at

>+1/+4.

>No clonus. Normal Webber and Rine. Decreased vibratory sense right lower

>extremity. Prorpioception normal. Antalgic gait. No tremor. No ataxia.

>MENTAL STATUS: Not oriented to person, place or time. Says he is Al Capone

>and this is " Valentine's Day in 1936. Consciousness is episodically cloudy.

>Answers are approximate. Patient exhibits preservation, echopraxia and

>echolalia. Doesn't recall what he ate for breakfast or lunch. Cannot name

>two states that adjoin Tennessee. Thought processes concrete. Intellect

>appears low normal. He has multiple somatic complaints but they change with

>physical exam. When told that " The leopard killed the lion " , he was asked,

> " Who won? " He answered. " The Boston red Sox-but this year only. " When

>asked why people who live in glass houses should not throw stones he

>answered. " Glass is expensive. " When asked the President of the United

>States he says " I like Ike. "

>

>LAB: Tox screen (+) THC

>CBC: WNL (except macrocytic anemia)

>

>BMP: Normal except Na+ of 148 mEq/L.

>

>LFTs: Mild elevation ALT, GGT.

>

>MRI of Head: Diffuse mild atrophy. No changes on heavily weighted cuts.

>

>UA: WNL

>

>What now?

>

>

>

>

[Guest guest]

>>> LAB: Tox screen (+) THC

What is the pot laced with??

Since he has had a " bug " problem...any mushrooms growing in his

apartment?

It's a valid question...Willie had them growing in his tour

bus..;-)

Jules

________________________________________________________________________

Check Out the new free AIM® Mail -- 2 GB of storage and

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[Guest guest]

I'd like to know what his CD4 is and whether or not he's been tested for HIV

or other CTDs. I doubt that the +THC has anything to do with this AMS unless

it's been adulterated. The formaldehyde thing is a possibility though.

The big question to me is whether or not this is an acute thing or an evolving

thing.

22 years ago HIV was just coming into focus, and dieners were usually working

barehanded and without respiratory protection. Neuropathy is a distinct

possibility with HIV and syphilis both.

He takes Zoloft, so, one supposes that he's been diagnosed with depression.

Why is he depressed? Do we know his sexual orientation? Is the THC a

self-treatment for depression?

Gene G.

[Guest guest]

May be way off here, but I'm going to give it a shot. I think the

whole question-and-answer pattern reveals something

called 'approximate answers.' That, combined with echolalia and

echopraxia, makes me guess that it's something called Ganser syndrome.

>

>

> In a message dated 9/21/2006 7:46:05 AM Central Standard Time,

> bbledsoe@... writes:

>

> He worked for 22 years as a diener.

>

>

>

> Am I the only one who is willing to admit that they had to google on

his job?

[Guest guest]

In a message dated 9/22/2006 8:43:10 AM Central Standard Time,

petsardlj@... writes:

Please explain " Ganser Syndrome " I have never heard of this type of

disease/phenomenon.

Google is your friend....

_http://www.emedicine.com/med/topic840.htm_

(http://www.emedicine.com/med/topic840.htm)

ck

S. Krin, DO FAAFP

[Guest guest]

We have a winner. It is Ganser syndrome.

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of

Sent: Thursday, September 21, 2006 11:00 PM

To: texasems-l

Subject: Re: A Little Clinical Thinking Needed

May be way off here, but I'm going to give it a shot. I think the

whole question-and-answer pattern reveals something

called 'approximate answers.' That, combined with echolalia and

echopraxia, makes me guess that it's something called Ganser syndrome.

>

>

> In a message dated 9/21/2006 7:46:05 AM Central Standard Time,

> bbledsoe@... writes:

>

> He worked for 22 years as a diener.

>

>

>

> Am I the only one who is willing to admit that they had to google on

his job?

[Guest guest]

Please explain " Ganser Syndrome " I have never heard of this type of

disease/phenomenon.

" Bledsoe, DO " wrote:

We have a winner. It is Ganser syndrome.

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of

Sent: Thursday, September 21, 2006 11:00 PM

To: texasems-l

Subject: Re: A Little Clinical Thinking Needed

May be way off here, but I'm going to give it a shot. I think the

whole question-and-answer pattern reveals something

called 'approximate answers.' That, combined with echolalia and

echopraxia, makes me guess that it's something called Ganser syndrome.

>

>

> In a message dated 9/21/2006 7:46:05 AM Central Standard Time,

> bbledsoe@... writes:

>

> He worked for 22 years as a diener.

>

>

>

> Am I the only one who is willing to admit that they had to google on

his job?

[Guest guest]

It is limited to the panhandle of Texas.

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of Danny

Sent: Friday, September 22, 2006 8:34 AM

To: texasems-l

Subject: RE: Re: A Little Clinical Thinking Needed

Please explain " Ganser Syndrome " I have never heard of this type of

disease/phenomenon.

" Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) <mailto:bbledsoe%40earthlink.net>

net> wrote:

We have a winner. It is Ganser syndrome.

_____

From: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com

[mailto:texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com]

On

Behalf Of

Sent: Thursday, September 21, 2006 11:00 PM

To: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com

Subject: Re: A Little Clinical Thinking Needed

May be way off here, but I'm going to give it a shot. I think the

whole question-and-answer pattern reveals something

called 'approximate answers.' That, combined with echolalia and

echopraxia, makes me guess that it's something called Ganser syndrome.

>

>

> In a message dated 9/21/2006 7:46:05 AM Central Standard Time,

> bbledsoe@... writes:

>

> He worked for 22 years as a diener.

>

>

>

> Am I the only one who is willing to admit that they had to google on

his job?

[Guest guest]

I am sure it is and I am sure I will catch it. : /

" Bledsoe, DO " wrote:

It is limited to the panhandle of Texas.

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of Danny

Sent: Friday, September 22, 2006 8:34 AM

To: texasems-l

Subject: RE: Re: A Little Clinical Thinking Needed

Please explain " Ganser Syndrome " I have never heard of this type of

disease/phenomenon.

" Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) <mailto:bbledsoe%40earthlink.net>

net> wrote:

We have a winner. It is Ganser syndrome.

_____

From: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com

[mailto:texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com]

On

Behalf Of

Sent: Thursday, September 21, 2006 11:00 PM

To: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com

Subject: Re: A Little Clinical Thinking Needed

May be way off here, but I'm going to give it a shot. I think the

whole question-and-answer pattern reveals something

called 'approximate answers.' That, combined with echolalia and

echopraxia, makes me guess that it's something called Ganser syndrome.

>

>

> In a message dated 9/21/2006 7:46:05 AM Central Standard Time,

> bbledsoe@... writes:

>

> He worked for 22 years as a diener.

>

>

>

> Am I the only one who is willing to admit that they had to google on

his job?