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The workup, or Where is Champollion when we need him?TranslationChief complaint: A 47-year-old white woman was broughtin by ambulance because of bright red blood perrectum over the past 12 hours.History of present illness: This is a patient with insulindependent diabetes mellitus and atheroscleroticcardiovascular disease, who has been in atrial fibrillation,and had bright red blood per rectum 12 hoursprior to admission, so was brought in by ambulanceto the emergency room with low blood pressure andtachycardia. She had no complaints of nausea, vomiting,diarrhea, constipation, or abdominal pain. Notravel. She’s on an American Diabetes Associationdiet. There was no past history of gastrointestinalbleeding, hepatitis A, B, or C, ethanol use, or pepticulcer disease. No prior diagnosis of inflammatorybowel disease (ulcerative colitis or regional enteritis).She has chronic renal failure with creatinine2.0–2.8mg/ml. She’s not on hemodialysis.Past history: She had urinary tract infection with fever andchills, caused by E. coli, 2 months prior to admission,treated with ciprofloxacin with no complications.She’s had coronary bypass graft two years prior toadmission, left anterior descending and right coronaryarteries. Her echocardiogram was within normallimits for ejection fraction six months prior toadmission. She’s had no chest pain.She is gravida 4 para 4, all full term vaginal deliverieswithout complications.She has no past history or family history of arteriovenousmalformations or cancers. There has been noincrease or decrease in her weight.Medications: She takes NPH insulin, 24 units each morning(glycosolated hemoglobin measurement averages6-7), and digoxin 0.125 mg each morning, an angiotensinconverting enzyme inhibitor, and one aspirin,85 mg per day.Social history: She is a certified public accountant with abaccalaureate of arts in economics, now on supplementalsecurity income. She’s smoked one pack perday of cigarettes for 12 years. She has had no sexuallytransmitted diseases. She does not have intravenousdrug abuse.Family history: Noncontributory.Review of systems: Noncontributory.Physical examination:Vital signs: Blood pressure 100/62, Pulse 120, irregularlyirregular, no orthostatic changes, respirations12, temperature 97.6, pulse oximetry98% on room air.Head, eyes, ears, nose, throat: Pupils equal, round,reactive to light and accommodation, extraocularmuscles intact. Sclerae anicteric; oropharynxand tympanic membranes withinnormal limits. Air conduction greater thanbone conduction bilaterally.Head: normocephalic, atraumatic.Skin: no spider angiomata, icterus, petechiae orecchymoses.Neck: No jugular venous distention. Supple.Pulmonary: clear to auscultation and percussion.Heart: No murmurs, rubs, or gallops. In atrial fibrillation.Abdomen: No palpable liver, kidneys or spleen; nottender to palpation.Bowel sounds present in 4 quadrants.Rectal: brown stool, Hemeoccult positive. No brightred blood. Hemorrhoids present.Pelvic: deferred.Extremities: no clubbing, cyanosis or edema.Neurological: Cranial nerves 1-12 within normal limits.Deep tendon reflexes symmetrical. Noperipheral neuropathy. Mental status withinnormal limits.Laboratory: Hematocrit 28, fingerstick blood sugar 139mg/ml.Chemistries: Na 138, K 4.2, Cl 111, CO 2 25, creatinine 2.0,blood urea nitrogen 14 mg/ml.Urine analysis was within normal limits.Liver function studies: albumin 3.8 Gm/ml, AST 22, APT 25and bilirubin 1 mg%. INR was 1.1Digoxin level was pendingElectrocardiogram: Atrial fibrillation at a rate of 110. QRSand QT intervals normal. Nonspecific ST-T wavechanges.Impression: Hemorrhoids.Plan: Preparation H, Sitz baths, discharge home.The author’s address is:University of California, Davis4150 V Street, Suite 1100Sacramento, California 95817E-mail: anna.raffetto@ucdmc.ucdavis.eduThe Pharos/Autumn 2004
Image by Robert KatoOutNo propriety. The johnny-shirt tied looseas the slab underneath slides out and lighthits unadjusted eyes. Thirty minutes isa long time to search for blight, nests ofcerebellar locusts, the exact site of pestilence,and then to see vast, white emptiness outside.The machine sits and technicians, nametags attached,guide noninitiates—plebes who’ve seized,gone blind, or otherwise lost their sense—from the room. I’m exposed, in partial clothes,and barefoot identity’s more than the lossof health but also less—the businessof symptoms and diagnosis, but also shiversto keep warm and ask the question: what’s next?Shane Neilson, M.D.Dr. Neilson is a resident in emergency medicine at DalhousieUniversity in Nova Scotia. His first book was published in November2003 by Frog Hollow Press, Victoria, British Columbia. His addressis: 429 Gardiner Street, Oromocto, New Brunswick, Canada E2V1G3. E-mail: itchscratch@hotmail.com.The Pharos/Autumn 2004 31
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