The doctor entered the cubicle taking time to size up the patient before him. Toxic incoordination coupled with droopy nystagmic eyes suggested that a breath alcohol test would be redundant, if even possible. Nothing unusual at 2 am in an emergency department.
“I understand you have a sore leg?”
There was not so much as a murmur in response.
“Which leg hurts?”
The patient snorted herself into a semi-coherent state.
“The right one, the pain is in that one” she said, while pointing at everything in the vicinity as she (presumably) tried to fix her gaze on one of her legs.
The doctor began to examine the right lower limb.
“I said the right one!”, grunted the patient.
“This is the right one.” Replied the doctor with equanimity.
“Well… I mean the left one!”
The doctor examined the left lower limb, but could find nothing wrong. Knowing that some things are clearer in the light of day, the doctor fetched the patient an extra blanket as she drifted off to sleep.
About Chris Nickson
Is that methanol intoxication? Visual disturbance and alcohol breath would suggest that.
>99% of such patients sober up and wander off in the morning, with no ill effects. Rarely, they turn out to have a significant head or spinal injury (usually superimposed on their intoxication), toxicological curiosity, or mimic (neurological conditions including Wernicke’s).
The balance usually means that an adequate examination, drug history, BSL, and dose of thiamine for everyone where any doubt exists, and more importantly serial observation should follow the usual course for alcohol (steady improvement, usually clinically resolved 4-6h), should be recommended for everyone.
I wouldn’t be doing VBG for acid base / ELFT unless I had a good reason.
Don’t forget that what you are examining is cerebellar dysfunction. Alcohol intoxication is just part of the differential, even if it’s prevalence is overwhelming.
Though 15% of otherwise normal people have right-left incoordination. I once worked with an intern who had to write L and R on the backs of her hands to remind her which was which.
A patient with a Gerstmann syndrome got drunk would be a very unusual case
If you have Gerstmann syndrome you can’t keep count of the number of drinks you have had.
I had a similar patient the other night -- was just about wrap him up for the night then his temp got measured… was low. Was it accurate?
Rechecked as T 31.8C and the ECG showed Osborn waves and a lactate of 8…
C
Ah Chris. That case sounds pretty much like any Thursday in my ED.
I would apply the “sandwich filter”
Offer a sandwich and a cuppa tea. If refused by the patient then assume serious pathology and do a heap of exam, vbg, US etc.
If sandwich is consumed you can discharge to “home”
Now I just need the computer folk to include “no fixed address” or “oval” in the system for a discharge destination ;-/
Yes, blanket seeking behaviour is rife in my neck of the woods too -- especially with the icy nights of the Central Australian winter.
C
I love the Sandwich Filter concept. Is there any disease process this won’t work for? Could save the health service $billions.
Wikipedia brought me here: http://www.thepoisonreview.com/2012/06/07/acute-cerebellar-syndrome-think-methoxetamine/. Methoxetamine (special k), not sure if they have it round your way. Could just be the EtOH, but ideally you would want some kind of alcohol level to be sure
I recently added methoxetamime to the review of new recreational drugs in the post ‘Life in the TOO Fast Lane’: http://lifeinthefastlane.com/2010/12/life-in-the-too-fast-lane/
Chris
Love the pic in th thumbnail (I have a print of that painting)