headache

Mrs M is one of those "heart-sink" patient. One that you try to avoid to see in your morning ward rounds.

I assume, for one reason or another, she hasn't been looking after her health for years. She has poorly controlled diabetes, on inuslin, had her leg amputated a few years ago and she still smokes. At a young age of 53, she was put on warfarin for her PAF some years ago. Strangely, her INR hasn't been all that bad.

She came in 4 days ago, with 1 week history of vomiting and diarrhoea. BSL was 30. The admitting registrar's impression was: "mild HONK, gastroenteristis, dehydrated".

On the ward round the next day, we tried to control her blood sugars better by adjusting this and that. Requested a diabetes nurse review... etc, hoping she'll be well enough for discharge within the next 24 hours. Why should we kept patient in hospital when they don't stay in the ward and keep wondering off smoking?

Day 1, dry retching somewhat settled. Day 2, a little better, but she still looked miserable. Day 3, she told us that she has a headache.. "how long has it been there?" I asked, as I was about to walk out of the door.. "3 weeks", she said quietly.

Well, that prompted me to do a full neurological exam, for there was a Fourth year medical student with me on the round, I can't really dismiss a complaint like that. Fundi looked normal, no focal neurological defect, no neck stiffness, no history of head trauma recently.. well, no red flags to her headache really.

A CT was ordered anyway, as she just didn't look right.

The CT showed acute on chronic subdural haematoma, with midline shift that even a fourth year student can see. She was transfered for neurosurgery within hours after the CT scan.

I wonder what's the moral of the story.

Headache from the Annals

Etiquette-Based Medicine

An article from the NEJM stated the obvious - a bit of manner goes a long way

Tears

I, along with a few in my team cried today. At work. Towards the end of a family meeting.

My role was to explained to Mr T, a non-resident who's been here for many years, and his family, that his immediate short term prognosis is grave. That there is no immediate cure to his cancer. Because he is not a resident, we're limited in how we can treat, and support him.

I, along with the rest of the team, all managed to "keep our cool", until Mr T, a Tongan man who, still have all his mental facilities intact, graciously thanked us for what we have done.

We were moved, genuinely moved by his generosity. For we have done so little. Our tears may also be an indictment to the care our dying patient receives.

a nation .. finds its better self

The cover of the Europe, Asia, and South Pacific edition of Time.