Wednesday, December 28, 2011


A young service-member checked into the clinic the other day with a complaint of 'dizziness'. I asked the tech if it was 'light-headedness' or 'vertigo' and got a blank stare so I just asked them to check them in to me.

Seems three days prior while driving this young man had sudden vertigo while driving and had to pull the car over for a bit. No headache, but also noticed, after getting home, that walking was a bit difficult and that holding things in his right hand was a bit dicey.

So three days later he comes to the clinic and I tell him he has to go to the ER because he has likely had a stroke. He helped me in this diagnosis by being Romberg positive, ataxic, and dysmmetric.

The ER calls me back a few hours later and says they are going to send him home. The CT was normal. Probably a medication reaction. Home? What did the MRI show? Huh? You didn't get one?

They got one after I made a few points and whaddya know.... stroke of unclear age. I was glad I advocated for the MRI. So, I ask you, my peeps. What happened next? And oh by the way, the guy's head hurt a bit.... not all of a sudden, but he had a headache.

Take it away!


  1. dymetria, ataxia , and dizziness all suggest AICA or PICA cva. was there any trauma involved? is it possible that this guy had an avm or berry aneurysm?

    hope he's doing ok.


  2. whaddya know, you thought he was sick too... and this is not really a 'guess the diagnosis' case... it's a 'guess what the ER did with him' case... me being now, mostly, NOT in the ER.

  3. sent him home, told him to follow up with neurology. which, in the case of tricare, means follow up with neurology in two months.

    ..and put him on aspirin and plavix?


  4. Whats next?
    Tebow wept.
    Funny, I had the same thang happen to me when I was a young Service Member, didn't go to the ER, probably cause I was embarassed about playing with my member while driving...
    And I know, lots of young guys jerk off while driving.
    But I was on my Bought-With-Federal-Student-Loan GSXR 750..WHOA!!!!!!!!!
    They are called "Crotch" Rockets...
    and aren't you in Georgia? Can't you get Mark Richt to heal him or something?
    Seriously, from my whole 2 days of Navy Flight Surgeon Neurology training, I think your dealing with a textbook case of "Oval Window Rupture" which usually happens when an FA-18 pilot does a negative G Mach 1.2 pitchover like Maverick did with that Mig-29, in the Best Movie of All Times that I'd bet my left nut the Muslim-in-Chief has never seen, "Top Gun".
    OK, the only case I saw was when a pilot got slapped for tellin a Hooter's waitress her vagina stank, and I didn't ground him, cause we weren't the Sissy Air Force, and even if he crashed, everybodies Oval Window ruptures when they hit the ground at 600mph, so there's no way the Board of Inquiry would be able to blame it on me...


  5. ER gave him 600 mg aspirin. Should help with both headache and secondary stroke prophylaxis, they thought. Discharged
    stroke of unclear age+ headache, they assumed the need for decompressive craniotomy. Sent him to neurosurgery services.


  6. They imaged his arterial system from the arch up, found the dissection in his vertebral artery even though he has no trauma history and anticoagulated or stented him, since he still had some viable brain tissue in the relevant distribution?

  7. They amputated his right hand and then scheduled him to play with a therapy puppy (his rehab program). Done.


  8. ''Tebow wept''.... Classic. And the answer is tht they sent him home to follow up with his primary car physician... i.e., me. I mean, call me crazy but when someone can't walk straight I either wait for them to sober up or I admit them or both. So he will get his stroke workup ten days after the fact. Odds are that will be okay.

  9. Ah darn, sent him home was my second guess......okay give me another try at reading the the guy goes home and has a dominant side MCA stroke, because his actual problem is that he has a DVT after his recent ACL repair and also has a anyways, since he can't move or speak it takes him a while to get to the emerg and when he gets there they chew him out for 'not coming sooner'?

  10. Headaches from the Spinal Tap.
    And I'm standing by my Diagnosis of Oval Window Rupture, cause anyone can diagnosis a boring stroke, but whens the last time you typed "Oval Window Rupture"? Hmmm?? you'd get finger cramps. And if you don't like that mis-diagnois I have others.
    And I like Tebow, reminds me of a young Me, the Adonnis Physique, youthful Innocence, Lefthanded, and a Nose that needs its own zipcode...
    I don't even mind the Evangelical Christian-ism, there the only friends Israel has anymore, which is why I sent him those photos of my daughter...


  11. actually frank,
    that's my point... evidently the fine civilian-stand-in-for-er-doc could not, in fact, diagnose a stroke. but the round window rupture thing is fascinating and i hope it never happens to me because if i remember correctly, once you get it, you never stop puking... kinda like what will happen if 'bama wins the natl title.

  12. 9-11,
    If #&*%*! Alabama wins the National Title, I'm pullin up stakes, growin a beard, and joining the Taliban/AlKaida/PLO, cause there's no way any Surpreme Beeing worth His salt lets a School with Toothless-Cracker-fans who poison other teams Trees, and not even win there Division, make it to the Title game.
    And that Tornado wasn't enough, I want Plauges, First Born Sons Slaughtered, or at least a few Starters with ACL tears.
    I mean, all my teams players do is take under the table payoffs and commit Home Invasions(during the Off Season, of course).
    So as much as it pains me to do so, I'm pulling for the only Division 1 Team with a certified Water-head for a Head Coach...
    Thats right, Les Miles, who can't count to 21 without takin off his pants.


  13. PS,
    Its "Oval" Window, not "Round" window.
    I mean there IS a "Round" Window, its got its own separate Wiki-pedia entry and everythang, but it doesn't cause problems nearly as often as the "Oval" Window.
    You know, like how the Incidence of "Oval Window Rupture" is like 1 in 999,999,999,999,999,999,9999,9999,999....
    Round Window Rupture's even rarer than that.
    Ask that Sissy-Boy ENT next time you see him, then stomp on his foot when he starts to correct your terminolgoy.

  14. Frank,
    I already pictured you with a beard, and the wierd pseudo-rasta hair things and that almost-Ahmish hat... of course i pictured you in Air Jordans at the same time and with a shoulder-holster and maybe spurs on your boots. something like that. obtw, aubie is down to the freaking 'mr Jefferson's Univeersity' football team. you can't lose to them. please do not lose to those assholes.

  15. It's interesting. You mention the patient had a positive romberg which goes AGAINST cerebellar dysfunction. Romberg tests for proprioception. If the patient has a cerebellar dysfunction he will have difficulty standing upright in a stable manner regardless of whether his eyes are opened or closed. Closing the eyes (romberg) while standing essentially isolates the dorsal column sensory function (proprioception). Here's an excerpt wikipedia regarding this (The Romberg test is used to investigate the cause of loss of motor coordination (ataxia). A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception. If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature, that is, depending on localized cerebellar dysfunction instead.)

    --just another er doc.

  16. @9-11
    Nah, I'm still rockin a Buzz Cutt High & Tight fade, that I get at a Barbershop right out of that movie "Barbershop" in the City thats NOT too busy to Hate, East Point Georgia, which is actually in West Atlanta, probably to fool the Yankees...
    And yes it is my only regular interaction with African Americans, and even though I don't know my Barber's name, he DID used to cut "Kid"s hair from "Kid n' Play".
    Or maybe it was "Play".