First, it shows how a little testing can turn into a lot of testing to “rule out” diseases in the emergency department.
Second, it hopefully provides some good teaching points.
Third, the comment from the attending physician gave me the giggles. That will explain the title. But you have to read through the case to understand the comment.
I’m not going to discuss all the minute details of the case, only the major findings that contribute to the flow of the case.
A patient got sent in from the nursing home because her gastrostomy tube was leaking blood and the nursing home was convinced that the patient was having GI bleeding. When the bandage over the patient’s G-tube was removed, it was fairly obvious that the skin about the G-tube site was the source of the blood. The skin was raw and was oozing dark red blood. Flushing the G-tube produced a little blood, but the blood cleared. The patient’s vital signs were stable except for a mildly elevated pulse. Proper skin care probably would have resolve the bleeding. Some people may have left it at that and sent the patient back to the nursing home. I drew labs and did an abdominal series.
The patient was mildly anemic. Her hemoglobin was 11. There was no blood in her stool. Her BUN was mildly elevated at 24 which suggested that she was behind in her fluids but not that she was having a significant upper GI bleed. With significant GI bleeds, BUN tends to increase quite a bit when the body digests blood.
The abdominal series showed that the G-tube was correctly placed and that there was no free air under the diaphragm. However, the chest x-ray showed another worrisome finding. In the bases of both lungs there was scarring and some placques that went along with the patient’s exposure to asbestos many years ago. However, the patient’s mediastinum was maybe just a lit-tle wide. There are a couple of measurements you can use to make that determination. Width > 8 cm on a PA view of the chest. Ratio of mediastinal width to chest width > 0.38. We used to say if the width of the mediastinum on the x-ray film was greater than the width of your pager, that was a problem. Now the youngsters don’t even know what a “hot light” is and some of them haven’t even heard of a pager. How wide is an iPhone these days?
Anyway, if the mediastinum is wide, there are several significant life threats that need to be at least considered. Aortic aneurysm, aortic dissection, and cancer are probably the most concerning to the emergency physicians. CT scan of the chest with contrast is one way to test for those conditions.
So the patient with a minor G-tube problem was now getting a CT scan of the chest. Obviously something that many would consider an “unnecessary test” for the complaint of a GI bleed, but a rabbit hole that warrants jumping into during the workup of a markedly abnormal chest x-ray.
Because the GFR was a little low, the patient got extra IV fluid before the scan to try to avoid contrast nephropathy.
The CT scan of the chest comes back with a little surprise. The aorta was OK, but there was another reason for the patient’s wide mediastinum. The patient had a diagnosis of achalasia and wasn’t supposed to be eating anything. Turns out that the nursing home staff was giving her treats every now and then when the patient would complain about being hungry.
The reason for the patient’s widened mediastinum was that there was a HUGE esophagus and that the esophagus was full of undigested food. See the arrows on the CT scan.
So now we know the reason for the patient’s widened mediastinum.
I called up the patient’s nursing home doc. He agreed that the patient would need to be admitted for management of the achalasia in addition to further evaluation of the possible GI bleeding.
Then he cracked a comment that made me laugh. When discussing the consults that he wanted on the case, he mentioned “Oh yeah, and you better get GI on the case, too. There’s no sense in leaving all that food in there … unless you want to make a fricking winter sausage or something.” Yes, I almost hurled the eggs that I had eaten for breakfast that morning. Then I laughed.
Before the patient was brought to the floor, I checked on her to see how she was doing.
“Can I have a little water?” She asked.
“How about I get you some ice chips for now,” I said.
“And a few graham crackers? She continued.
“Nothing to eat for now, OK?”
Mmmmm. Graham cracker sausage and eggs.
Of course after I told everyone about the sausage comment, no one felt very much like eating lunch. And the rest of the day we’d walk by each other in the hall saying “mmmmmmmm” and giggling at each other.
No, dear patients sitting in the hallway and giving us odd looks, we’re not crazy. Just a little weird.
One favor for those of you who got this far. I’m changing a few things on the blog soon and would like some feedback to help guide me on the changes. Cases like this take extra time for me to write, review, and reference. This post took me almost 2.5 hours to write. I know that both medical providers and patients read this blog, so I’m wondering whether you felt it was worthwhile.
I want to try to hit a sweet spot between posts like this being informative for providers but not so technical that patients don’t enjoy them. Please answer truthfully – you won’t hurt my feelings.
Any comments about how to make posts like this better would also be appreciated. Straight up cases? More patient interactions? Pictures? No pictures? More links? Less links?
Also, if you have an interesting case you want to write up and post, drop me an e-mail. I guarantee anonymity and HIPAA compliance.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.