Neurology Avoids Disaster Admission, Admits to Medicine

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HAMPTON, CA – Kaiser Health Hospital had a close call this Wednesday.  Thanks to the diligent efforts of Dr. Trevenstein, a neurology attending at Mercy hospital, a patient was appropriately admitted to the hospitalist service, narrowly avoiding being on a highly-specialized neurology service.

I would love to consult, but this stroke seizure Parkinson's ALS patient doesn't quite fit the neurology picture
I would love to consult, but this stroke seizure Parkinson’s ALS patient doesn’t quite fit the neurology picture

Mrs. Negevny, a community living 73-year old, was evaluated in the ED with progressive left upper extremity weakness and slurred speech.  After the EM resident activated the stroke team based on the chief complaint, Mrs. Negevny was evaluated by Dr. Trevenstein and hospitalist Dr. Singh as part of the stroke protocol.  After determining that the symptoms have been ongoing for 2-3 weeks, Dr. Trevenstein dropped a quick consult in the chart and headed back to the office, entrusting the care to Dr. Singh.  A subsequent phone interchange was captured on tape:


Dr. Singh: I’m calling about that stroke code in the ED.  Just want to make sure you will be taking her on your service.

Dr. Trevenstein: Yeah, but she was way past the TpA window, so there is not much for us to do.  Admit her to medicine… Put her on telemetry… MRI/MRA carotid dopplers, statins… you know all the good stuff.  We’ll consult.

Dr. Singh: Right, but this is a pure neurology case, I think that the patient would be better off with you.

Dr. Trevenstein (after diligently checking the lab results): Let me look at her labs.  She has some WBCs in her urine… So it’s a UTI, so admit to medicine.  We’ll consult.

Dr. Singh: You know I’m looking through her chart, and she also has Parkinson’s.

Dr. Trevenstein: Yeah, but we really cant admit a patient to neurology who has an active UTI and is possibly septic.  We’ll follow along.

Dr. Singh: You know, I’m looking around a bit more and she also has multiple sclerosis… on betaseron and Tysabri.

Dr. Trevenstein: Yeah… but you know… UTI.  I have not idea how to deal with this.  I just looked at her labs again and she has 4+ epithelial cells in the her urine.  How the hell did those get there?  Sounds bad.

Dr. Singh (as he flipped through the chart some more): She had PRES (posterior reversible encephalopathy syndrome, a rare and puzzling swelling of the brain) in the past.

Dr. Trevenstein: UTI.  Is no joke in my book…

Dr. Singh (interrupting): Oh wow!  Carries a history of ALS!

Dr. Trevenstein: UTI… Do you treat that with antibiotics, still?  Have they made any new ones since penicillin?  I’d hate to play around with those drugs.  But we’ll definitely consult.

Dr. Singh: You know, she was seen for generalized tonic-clonic seizures in your clinic just last week.

Dr. Trevenstein: After you treat the UTI, get an EEG, MRA/MRI.  I’ll even talk to the tech for you.  We’ll make it happen before Friday.  Admit to medicine.

Dr. Singh: She’s having an active seizure right now!!  4 of Ativan IV stat!!!

Dr. Trevenstein: She is also having an active UTI.

Dr. Singh: Huntingtons!

Dr. Trevenstein: I’ll have to get our resident on this consult.  May be an interesting case.

Dr. Singh: Devics (extremely rare disease where body attacks nerve fibers involved with visions)!

Dr. Trevenstein: UTI.

Dr. Singh: Myasthenia gravis.

Dr. Trevenstein: UTI.

Dr. Singh: Guillain-Barre.

Dr. Trevenstein: That’s not a real diagnosis. It’s now called AIP (acute idiopathic polyradiculoneuritis).

Dr. Singh: Chiary Malformation, Meigs Syndrome, MELAS, Kluver-Bucy syndrome.

Dr. Trevenstein: UTI, UTI, UTI and I’m pretty sure you made that last one up.  Admit to medicine.

Dr. Singh: You will consult?

Dr. Trevenstein, (Doing everything he can to assure his colleague): I will send the resident in the morning.

At this point Dr. Singh called the admitting medicine resident to initiate admission.  When asked about the “quick story” on the patient, he blurred out “UTI.”

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