Just a little wobbly

If it was any of the organs systems that seem to scare me as a general practitioner, it is probably neurology. It is something that can be so subjective, and non specific in general, with sometimes no notable significant neurological signs. In particular, dizziness is one of my pet hates. But when there are actual demonstrable neurological signs, that’s when things get interesting.

A couple of weeks back, I had the fortune of seeing such a gentleman with significant pathology. He had spent the weekend at a location about 8 hours drive from where I work, doing a bit of crane driving for a mining project.

His daughter accompanied him in to the practice.

“Doctor, I’m concerned about my father. Today is the first day I’ve seen him back after his weekend job, but he is not himself. He can’t even walk properly. Something is seriously wrong.”

Unfortunately, it was the first time I had seen this gentleman, so I had no baseline to compare his current self with. What I did notice, was an unsteady gait however.

On exploring his history, he had apparently been involved in a truck rollover accident, for which he went to a tertiary hospital and had head scans which did not reveal any significant bleed. He was not on any anticoagulants or blood thinners, and had no significant past medical history.

Examination revealed 3-4/5 weakness of the left upper and left lower limb regions in power, with cranial nerves intact. PEARL

Thinking this could potentially be a stroke, a CT brain was ordered. The radiologist phones me up.

“The CT brain scan has some significant findings with bilateral subdural haemorrhage and a 5mm midline shift. ”

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That was all the information I needed for an urgent referral to the Emergency Department.

A few weeks later, I see the man again, and he is walking normally.

“Doc, they cut my head open and drained out all the blood. I’ve just come in to see you to determine if my staples are ready to come out yet.”

A neurological examination was completely normal. Here was a man who a few weeks ago, had trouble walking and seemed vague at times, and now he was walking normally with everything back to normal.

It was at that point that I marvelled at the wonders of modern medicine and how much of a difference could be made to the patient.

The patient later revealed that apparently, the hospital were not certain if there was a small bleed in his brain 6 weeks ago after his truck accident, and had advised him to return for regular check up with information advising him of this. He didn’t read that information, so didn’t think much of it. This may have lead to a continuous ongoing bleed, up till the time of presentation when there was too much blood present.

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Postnatal Checks

Having been on obstetrics and gynaecology, I have had to do a fair few postnatal discharges as a resident.

These postnatal discharges are quite repetitive I must say, in that it’s always the same questions. You find out how they delivered their baby, what blood group they are, whether they are rubella immune or not, what complications arose in labour etc.

With any woman that has had a 3rd or 4th degree tear, they have to had opened their bowels before they are allowed home. In addition, they must be getting regular laxatives (usually lactulose) while as an inpatient.

Around the time of Christmas, I see a woman who had a 3rd degree tear. She hasn’t passed bowel motions for the last 5 days. Reading through her notes, she’s been seen by previous residents, even had a general surgery consult in regards to exclude any anal dysfunction. I panic at the prospect that I have to see her.

I eventually decide that I need to see her everyday, after looking at the anus, and noting normal anal tone. She tells me that she’s starting to get abdominal pains, and I think I can feel the poo in her tummy on palpation. Poor thing.

For the next 3 days, I see her every day, always asking if she has pooed yet, and if she has passed wind yet. Still no. It’s about 2 days out from Christmas. The patient informs me “I really do hope that I pass a bowel motion soon. My wedding anniversary is on Christmas.”

I make light of the situation (it’s too good to pass) “Oh goodness. I sincerely hope that you won’t be in hospital waiting for a poo on Christmas and on your wedding anniversary!”.

Pumping her full of laxatives, the patient questions my medical management. “Is there anything else you can do aside from just giving laxatives? I mean I’m really concerned something bad is happening”. I reassure her that the abdominal x-ray series has excluded a bowel obstruction, and that we are giving optimal medical management.

“There is no other alternative aside from either manual disimpaction or inserting a tube up your anus to flush the poo out. But with your 3rd degree tear, those aren’t really good ideas”. The patient almost faints after I explain manual disimpaction, wriggling my index finger. “How will the index finger get the poo high upĀ out!!!???”

I think I was enjoying myself too much teasing this patient. Not in a mean way, but in a light hearted way so as to make the situation less serious.

After seeing her on the 3rd day, news gets out that she has some incontinence. Only a few mls according to the patient however. An hour later, and she has opened her bowels with a massive amount of faeces. I try to see the patient to congratulate her, but she seemed pre-occupied in the toilet. Unfortunately, I wasn’t able to see the patient as I had to rush off to the clinic. But I’m proud of the laxatives I gave this patient.

I feel happy for the patient. At least she doesn’t need to spend Christmas and her wedding anniversary waiting for a poo.