A Thanksgiving "mystery" from my residency days.
A case so unusual that it never happened, but very well could have. Can you solve it?
Every other year, I have to work Thanksgiving week. This year, it’s my turn to staff the ER. As it happens, I actually don’t have to work Thanksgiving Day this year. Instead, I worked last night, and I’ll work tomorrow and over the weekend. I actually enjoy working on major holidays, as I think many of my ER colleagues do. Humanity seems to “self triage”— less minor stuff comes in, but a normal volume of critically ill patients still show up needing our help.
It’s a good feeling, being there in people’s hour of need, even if it is a national holiday. We’re there for the people who need us, and there’s a special camaraderie among the staff. We know we’re helping our community in some small way just by being there—and there’s food and drink waiting for us at home.
Now onto the main dish. This year, I’d like to tell you about a case I “remember” from residency. It’s not a patient I actually took care of. In fact, it’s a case I made up entirely.
Back in residency, on weekday mornings, all of the junior residents and a couple senior residents would gather in the break room for “Morning Report.” There, the junior resident would present a mystery case that the audience had to solve.
From the get-go, the questions would fly from the peanut gallery. What were the vital signs? What did the patient say? What was the patient’s medical history. Eventually, we’d get to the physical exam. Next, we’d discuss the “differential diagnosis”—the list of diseases that could plausibly be causing the patient’s symptoms. From there, we’d talk about what tests we’d consider ordering. The presenter would slowly reveal the results, eventually leading to a satisfying diagnosis.
On one Thanksgiving Day, it was my turn to present at Morning Report. I stood in front of a blank white board, as always, and gave a “chief complaint”—the reason that a patient was coming into the ER.
The chief complaint was “fever and agitation.” His heart rate was elevated. His pupils were dilated. His body was a little tensed up and his reflexes were too good. When you tapped the tendon below the knees with a reflex hammer, the knee-jerk was stronger than normal.
It wasn’t long before my colleagues figured out that the reason my patient had a chief complaint of “fever and agitation” (and that it just so happened to occur on Thanksgiving Day) was not an infection—but due to a life-threatening condition that emergency physicians can’t afford to miss…