Orientation was largely aimed at the Riley kids, so A and I went over to find our places at Wishard. I got a whirlwind orientation, listened to rounds all morning, saw a whole two patients, one of whom was all in Spanish, and watched a lumbar puncture. There'll be new residents tomorrow. Otherwise, the next LP was going to be mine to perform. And if they don't mind, I'll still get it. "If you want," JK says. Do I want? No, I'm scared shitless. But I watched JH do the one on Tuesday and he had to stick the kid three times. I don't feel as bad now.
We tried to go to noon conference, but there was no food left, so we left too. JK released me to go get some food, look over the chart for LP-boy (he's your patient now), and page him when I was done.
I would've been done much sooner with all of that, except I had to go back to Wishard to get my wallet. And I forgot what floor the unit was on, so I went to second. And then fifth. And then fourth. And then third. And then I knew I was on the right floor, but all I could find was the NICU. And I couldn't get through the doors, and my card didn't work, and after 25 minutes or so, JH happened upon me. "Where are you trying to go?"
He laughed. And gave me directions. And I got my wallet, and found my way to the other side of Wishard where the cafeteria was. And I had taco salad, next time to be put in a small cardboard thingy instead of a large cardboard thingy, as there was entirely too much of it for my hunger. And then I went back up to the wards, finding my way with a relative lack of missteps, and I looked over the kid's chart.
D is 11, two months post-appendectomy, no significant history of migraines, and presented with a two-day history of headache and vomiting, unable tokeep anything at all down - including a teaspoon of water. Low-grade fever, photophobia, no sick contacts. (ishotkenney, are you thinking LP is a good idea by now in the history? Because I was.) He was seen in the ER, but lacked any signs of meningismus (no stiff neck, no Kernig's sign or Brudzinski's sign) so despite two consults with the doctor on call they didn't do an LP. What they did do, however, was start him on ceftriaxone. The question that comes to mind here is: If the ER doctors didn't think he had meningitis, what in the bloody hell were they treating with ceftriaxone?
We got an LP the next day, after one dose of ceftriaxone. Beautiful crystal-clear spinal fluid (on the third try), opening pressure 24.5 cm, just lovely. And the cell count came back 150 RBC's, 350 WBC's, normal glucose, normal protein. Probably viral meningitis - the white cell count, while elevated, is below 500; the glucose and protein are normal (decreased and increased respectively in bacterial); gram stain is negative - but we don't know, since he got antibiotics. There's a PCR for enterovirus (the most common cause of viral meningitis) gone out, but it'll be a while. So we wait to see if his blood - the only thing we have from before antibiotics were started - grows anything. That'll be late tonight.
By the time I was done looking through his chart, I had enough time to tag along over to the newborn side again, listen to a lecture on normal newborn exams, and talk through my expectations of the rotation and JK's expectations of me. I'm supposed to be a member of the team, and work through things with them, and present, and care for patients, and generally be useful. I'm good at being useful.
Then I went to Muncie, spent some time waiting for Angel's mom to get out of the evil meeting, wrote notes to my old professors, and generally had a good time. Also Applebee's for dinner. Got home around 9:45 or 10, at which point I did my looking up and patient entry and panicked over the stupid little abbreviations. It goes like this: There are two common labs which have abbreviations for the relevant data. One is the CBC. And it goes like this:
\ Hct / WBC ------- Plt / Hgb \(WBC = white cell count; Hct = hematocrit; Hgb = haemoglobin; Plt = platelets) The other, the one that I can never remember, is the electrolyte panel. Abbreviation I copied down from the chart is as follows:
Na+ | Cl- | BUN / -----+-----+----- Glc K+ | Co2 | Cre \(Co2 = bicarbonate level; BUN = blood urea nitrogen; Cre = creatinine; Glc = Glucose) But for some reason, I couldn't find the bloody thing. And I didn't look in Maxwell's. And so I had to wait for this morning because I'm too daft to know where they went just by normal ranges.
Was running late this morning by 10 minutes (I hate having to be there at 7 AM), missed Grand Rounds because I was busy talking to JK, scrambled to make my presentation by the time we did rounds, and felt very stumbly over it all. But ultimately, it went well. It all went well. I was complimented on my presentation, especially on the impromptu one I was handed over the new overnight admission. J's patient, she saw him in the ER last night, but JK had me presenting him and she was happy to let me do so. And that, O Best Beloved, was a most interesting case. Interesting enough that I'm going to make a game of it. Read on:
The patient is a four-month-old male. He lives with his mother, who despite a history of cocaine and marijuana use during the first trimester of her pregnancy, was clean after that (too bad so much development takes place then). He is a full-term baby with no known defects, spent 48 hours in the NICU after a difficult birth, all of his drug screens at the time were negative. Mother has two other boys, both in foster care, that she's working to be reunited with. He spends time with his father (who has several girlfriends, it seems) - and in fact, has been with his father for the last week. Mom picked him up at 1 PM yesterday. He was fine. He continued to be fine until he woke up from his nap around 10 PM, when she felt he was acting "not right" and brought him to the emergency room. That history is all from the father, who came to the ER last night and stayed with the baby while Mom went home to tend to the other kids. We didn't get Mom's history until the definitive labs were back.
My PE in the morning concurred with the PE of the ER: a baby who is alternately irritable and utterly passive without much interaction. When blood was drawn he could localize pain and withdrew from it, but quickly fell back to passivity after that.
He is afebrile (normal temperature). His head shows no signs of trauma, but his eyes have pinpoint pupils to 2mm or so, minimally reactive to light, and he won't open them spontaneously except for brief instances. During one of his crying spells, it was noted that he displayed horizontal nystagmus. This resolved spontaneously and did not recur during the next crying spell. His fonatanelles are flat, maybe even a bit sunken, his mouth is dry, and he's not producing much in the way of tears. Heart rate is regular, no murmurs, rubs, or gallops, and a sturdy 130 BPM. Brachial and femoral pulses are good. Lungs are clear. Abdomen is soft and nontender, no hepatosplenomegaly noted. He is moving all extremities, and grasps fingers. His skin is clean, a nice warm dark brown, and shows no bruises or marks of trauma. His LP site (they did one on him, oh yes) is clean and shows no signs of inflammation.
We have on file a CT scan of his head (normal) and a chest X-ray (normal, although I went down and made the radiologist explain to me why the funny lines I saw weren't rib fractures from abuse). And here, O Best Beloved, is where you come in. Just for fun :) Let's put you in my shoes, and see what you can think of...before I tell you about his labs. No grading, just a little fun. I have a handful of Medically Minded people here.
First things first was to look at the labs. I went through them all. They were all distressingly normal, even down to the LP results. It was a perfect tap: 0 WBC, 0 RBC. An unequivocally clean CSF. So we had to sort our differential: Ingestion vs. Seizure vs. Abuse. There are a number of other causes, but none of them were well-supported by the PE results.
The next step then, already handled by J in the ER the previous night, was to run a drug screen. Preliminary blood levels of alcohol, aspirin, and Tylenol came back negative. Urine screening for the major troublesome drugs (marijuana, cocaine, meth, PCP, barbiturates, benzodiazepines, etc) came back negative. She ordered the 600-drug urine screen. We ordered an EEG to see if he was having seizures, also compatible with his symptoms. We ordered an EKG to look for cardiac syndromes. We ordered an abdominal X-ray to see if he was having GI distress. And we waited. I wrote my progress note on D and went to noon report, had a sandwich, and played Tetris while listening to a woman talk about breathing support systems. But it was a free sandwich.
After lunch, my duties were to talk to D about his results and our plan, follow up on the EEG, write my H&P note on the baby, and then go follow C around the nursery. I wrote the note. I consulted D. I peeked at the baby - alert, awake, and responding to sounds appropriately now. Looking much better. Then I found JH and he sat me down. "Drug screen's back on the baby."
Positive for metabolites of risperidone. Risperidal, a fairly potent antipsychotic medication. In a four month old kid who can't even crawl yet. This, O Best Beloved, is Suspicious.
We finally got Mom's story, just before telling her what had been found. Her two younger kids take Risperidal for their behaviour. They had the medication with them last night. She denies giving the baby anything - she bathed him, he played with the others, she put him down for a nap. The staff at the rehab group she lives with gave the other two their meds. But it was a chaotic situation, and one I was glad to turn over to the social worker.
The bottom line? Well, we still don't know who gave the kid the drugs. There are multiple possible routes. And Mom, assuming that she's innocent of trying to sedate a cranky kid with nasty antipsychotics, is now getting involved with CPS just as she's working to get her other two back into the home. And Dad's furious. And it's all a nightmare. And I inherited him as a patient from J, who goes to a new rotation tomorrow.
After calling on the EEG (tomorrow morning) and checking in with JH, I was gone at about 4. Angel got the LCD screen for my uber-cute PS1, so I can now play DDR and Final Fantasy here. Now I'm pondering going to the store to buy some microwave dinnery things for quick meals, and get some more shakes, because I happen to like them for breakfast. And that, O Best Beloved, is that.