Proof I learnt something from you all!

After the case from the other week and Dr Casey Parker talking to me about using USS as much as possible to save on radiation I had this patient present to me on nights.

52 y/o male.

Had been chopping wood and fell backwards when he tripped on a piece. striking his R side on the block.

Very painful but given 3mg of morphine in ambulance and settled by the time he hit ED.

PMH Atrial fibrilation, on dabigatran.

Initial inspection below showed a large swelling with area of bruising centrally.

Palpation revealed it was tight and tender.  Abdo was SNT.

So im thinking bleed into lumbar sheath, but if only there was a way to image that at 11pm without radiology in the building. So I whipped out the USS machine and..

Sorry about the quality of the photo from my phone couldnt get it to take better.

Showed a 2cm by 8cm area of low density with some heterogenous material within this. felt consistent with bleed into lumbar sheath. dip urine negative for blood.

Oral analgesia, advised to stop dabigatran for 2 days.

Follow up:  Pt doing well. Impressive bruising which developed later not photographed sorry (saw him in the supermarket)

So it appears not only working out excessively but also chopping wood is to be avoided whilst anticoagulated (actually the chopping wood seems a bit more obvious)

DF118*

Another yarn, promise more proper cases soon.

We recently had a patient through whom is prescribed I/M pethidine at home for pain control. has episodic pain secondary to renal stones from medullary sponge kidney. We were all pretty uncomfortable but there was multiple letters from pain service and local anaesthetic service r/v as well. so to be honest felt pretty off but just prescribed as per “protocol” whilst they were in.

Go us to talking about chronic pain and difficult patients. Locum physician whos got a few grey hairs told me this tale.

He moved to a small rural town with a little hospital as one of his first general physician jobs.

His first patient to see in clinic was a lovely old lady with chronic pain from cervical spondylolisthesis. She had been on DF118 for almost 12 years with good results, no real complaints of pain. Her GP had passed away and the others at the practice felt that this was not appropriate and she was sent to see the physician to Review and decide on pain management. After long discussion he felt that continued DF118 was in order as she had done so well with it. But did not want to continue prescribing so wrote a script for 2 weeks and told her to return to her GP.

Later that afternoon he received a call from the local pharmacist. “What the hell are you doing prescribing DF118 for this old lady without the asterisk?” Confused He replied “excuse me?” The pharmacist went on to explain that the patient had been taking vitamin A pills for the last 12 years with good effect and that he knew to give the placebo to the scripts with the asterisk. Apparently the Old GP had a few tricks up his sleeve for those he felt needed some pain relief or at least thought they did.

a few shades of what?

Had an interesting patient this week.

presented at 11pm to ED.

58yo Male. Accountant.

came to ED with his wife. Quietly came to the desk and asked to see the doctor.

Taken to side room. removed his jeans and had a large number thin linear bruises over both buttocks and lower back. Laceration across Left buttock about 1cm deep and 4 cm long.

After some discussion patient explained that he and his wife had been “experimenting” after her recently reading an erotic novel. She had tripped a little or he had moved was unclear and she caught her heel on his buttock and caused said laceration…

Wound was closed with local, sutures. given course of oral ABx as who knows where those heels have been!

So it left me wondering is this the beginning of the tsunami of ED presentations secondary to BDSM….. Erika Leonard!

Bit of a yarn

Now for something a little different.

A story from theare. I was assisting with a lap appendix. when a theatre nurse came into theatre and feel the ground laughing.

After a considerable time she was able to calm down enough to tell me this story.

The orthopaedic theatre next door was performing an IM nailing for a extracapsular NOF. Pt had be taken to theatre pretty promptly as was found on floor but no concerns with U+E and space on acute list.

The operation had gone smoothly with the consultant supervising a registrar. Then as the registrar began hammering the nail it stopped. So he hit a little harder. He was then dressed down by the boss for being “a little girl” after which he hit a little harder. Then the consultant took over. after much hammering and swearing a larger hammer was requested, same result. At this time the medical student at the back of the theatre said very meekly “I think this patient might have had her knee replaced”

Pin-drop silence.

Said nurse had to make her speedy exit to our theatre to avoid life threatening orthopedic rage.

Radiology was called for and showed the reason for the nail stopping. The cemented Total Knee replacement… Sometimes even if your only tool is a hammer and you can use it well, its worth checking where the nail is going.

Rufus Arthur Johnson Syndrome

Anyone who gets the reference above im impressed as its obscure, moving on.

Patient 52 y/o presented to ED with abdominal pain.

Had been doing sit ups with a friend and had acute onset abdominal pain. no nausea, vomiting. afebrile.

Past medical history of AF on warfarin.

Exam showed small area of ?bruising on anterior abdominal wall associated with local tenderness.

Discussion with surgeons lead to CT abdomen. Shown here:

CT showed, Findings consistent with a left lower rectus abdominous haematoma.

Check Hb normal. D/C home, warfarin stopped for 5 days.

So to explain the reference as i feel i need to.

Rufus Arthur Johnson is better known as Bizzare from D12 he rapped the famous line.

“50 told me to do sit-ups to get buff. Did two and a half and couldn’t get up”

essentially the patients presenting complaint.

There you have it the first patient with Rufus Arthur Johnson syndrome.