When I was in residency, a staff member brought a young man to see me.
The young man couldn’t talk. He could make some sounds. His head was a funny shape, asymmetric. His mother had rubella during her pregnancy: German measles.
“His head hurts.” said the group home staff member.
“How do you know?” I asked.
“He isn’t acting right. There is something wrong. He’s different.”
“About a week or ten days.”
“Did he fall?”
“We’ve talked about that but we don’t think so.”
I tell the young man what I am going to do before each part of the exam. I look in his ears carefully. His ear canals are odd too and I can’t see well. His exam is basically pretty normal for him. He is not running a fever. He doesn’t have a stiff neck. He doesn’t seem to have nasal congestion.
“If he hit his head, he could have a subdural, a bleed pressing on his brain.”
The staff member shakes their head.
“Ok. I can treat him for an ear infection, though I can’t see that well. If that doesn’t work, we will have to image his head. Would he stay still in a CT scanner?”
“No.” says the staff member.
“Then I would have to set it up with anesthesia. Which is difficult.”
So we treated him for an ear infection. No improvement. He returned. Exam unchanged. The staff was still sure his head hurt. I had never seen him before the initial visit, so I couldn’t tell.
I set up the CT scan with anesthesia. Twice, because they mucked it up the first time and it wasn’t coordinated right. I had to explain to multiple people on both anesthesia and radiology what and why I was doing it. “His head hurts and he can’t talk?” I argued until they gave in.
The ENT chief resident called me with the results. Not radiology. “What?” I said.
“It’s the biggest pseudocyst we’ve ever seen!” said the ENT chief. Surgeon. “He needs surgery!” His voice said “Cool!”
In residency I’d noticed a striking difference between family practice and other residency folks: internal medicine, surgery, neurology, all the subspecialties. They got excited when there was something rare or weird. I always thought, oh, shit, my poor patient.
“What is a pseudocyst?” I actually didn’t ask, because they knew I was just a lowly family practice resident and would probably not have heard of a pseudocyst. A cyst like structure can form of snot in the sinuses and can cause headaches. It can erode through the bone into the brain. His hadn’t, thank goodness, because that can be bad. Bad as in lethal.
Because of the measles, he had some of the largest sinuses ENT had seen ever, and the largest pseudocyst. ENT happily took him off to surgery. Great case.
I got to see him in follow up. He was his normal self. His group home staff member was delighted. “He’s back to normal! Thank you so much!”
But it’s the group home staff that noticed and cared and brought him in. “Thank you for bringing him in,” I said, “I would not have noticed. And some people wouldn’t have cared.”
Differentiating pseudocysts and other things: http://www.oapublishinglondon.com/article/1266
More on pseudocysts: http://www.ncbi.nlm.nih.gov/pubmed/6595617
Pseudocyst images: https://www.google.com/search?q=maxillary+sinus+pseudocyst&biw=1366&bih=634&source=lnms&tbm=isch&sa=X&ved=0CAcQ_AUoAWoVChMIoZzWwv_QyAIVUJuICh248gGC
Rubella in pregnancy: http://www.marchofdimes.org/complications/rubella-and-pregnancy.aspx
Rubella, aka German measles: http://www.mayoclinic.org/diseases-conditions/rubella/basics/definition/con-20020067