Some bragging rights

The past two days have given rise to some interesting patients in my firm. To protect patient confidentiality I won’t be giving all the detail, but here goes:

A female with some cushingoid features, presenting with acute severe bilateral frontal headache and diplopia. She had papillodoema. Our differential diagnosis was subarachnoid haemorrhage, benign intracranial hypertension and glaucoma (in that order). The brain CT showed a pituitary mass lesion, which explains the pressure-effects. We are now waiting for confirmation from neurology and radiology of the type and so on. A macro-adenoma would explain the cushingoid picture too. We are also waiting on endocrine blood results.

An immune-suppressed patient presented with upper limb weakness and meningism. When I entered the ward yesterday he was having a generalised tonic-clonic seizure. His scans don’t show any indication of Tuberculosis. The doctors are planning to do a lumbar puncture for the JC-virus, which causes Progressive Multifocal Leukoencephalopathy (PML). It causes inflammation of the white matter of the brain at multiple foci. It is a demyelinating disease like multiple sclerosis, but progresses much faster. It is one of those viruses that is presumed to be dormant in a great many of the population, but kept under control by our immune systems.

We also had a middle-aged patient present with extremely decreased level of consciousness and a rapid HGT of “Hi”. That’s what the monitor does when the glucose is higher than 30mmol/ℓ. She is known with hypertension and epilepsy only and was severely dehydrated. Blood gas displayed respiratory acidosis and she had Kussmaul Breathing. We gave her a normal saline IV and treated the hyperglycaemia. The labs came back with a 72 for blood glucose. (!!)

My last patient has suspected Guillian-Barré syndrome, with a two-day history of lower limb paralysis and one day of upper limb paralysis. No cranial nerve fallout, no sensory fallout and no respiratory involvement. The history is slightly suggestive and she is areflexic, but we are still waiting for lab results – the doctor is not entirely comfortable with a diagnosis yet. The full name, by the way, is “Acute Autoimmune Inflammatory Demyelinating Polyneuropathy”.

At any rate, Internal certainly is not boring.

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