Sunday, November 27, 2011
Thursday, November 24, 2011
Tuesday, November 15, 2011
Bruce Wayne as seen in 1989-1990.
Patient BW, DOB 2/16/1971
by RUSSELL SAUNDERS on NOVEMBER 14, 2011
Patient: Wayne, Bruce
Emergency Contact: Dick Grayson, XXX-269-9637
Interval History: Patient was seen for his last annual physical approximately one year ago. Since that time he has had numerous visits for acute illnesses or injuries, generally accompanied either by his companion Mr. Grayson or Alfred, a senior member of his household staff. These recent maladies appear to be in keeping with the pattern that has emerged over the past several years, in which significant medical problems are associated with odd or incongruous explanations. Most recently, patient was seen for numerous areas of lower extremity cutaneous blistering, erythema and thickening, consistent with moderate to severe frostbite. Patient had reportedly gotten lost while camping in the mountains, but could not account for how he had sustained these injuries in mid-August.
Past Medical History: As stated, patient has a somewhat lengthy and complicated medical history, best summarized by system –
Orthopedic: By far the greatest contributor to patient’s ongoing morbidity are his multiple and seemingly ceaseless musculoskeletal injuries. The most significant of these was sustained several years ago, when he was rushed to GCGH with several fractures of his lumbar vertebrae, reportedly after falling while rappelling. Skeletal series obtained at that time revealed numerous (>20) areas of orthopedic injury in various states of healing, which could not be fully explained by recent fall, including areas of all extremities and many ribs; confirmatory bone scan similarly showed many areas of increased uptake. Patient’s robust stature is not consistent with osteogenesis imperfecta, and skin biopsy was negative for abnormal collagen and P3H1 or CRTAP genetic defects. Malignancy was suspected, but eventually ruled out following oncology consultation. Patient explained most of these (and most subsequent) injuries as being the result of membership in a private and apparently quite intense mixed martial arts club. Patient has denied being the victim of domestic abuse by Mr. Grayson following indirect and direct questioning on numerous occasions.
Neurologic: Patient has been evaluated numerous times over the past several years with complaints of headache, blurry vision, memory deficits, nausea and emotional lability. As with above injuries, most of these symptoms occur following some blow to the head during MMA sparring or competition, and were diagnosed as consistent with concussion. (Patient reports that the club frowns upon protective headgear, a stand with which he seemingly complies despite numerous exhortations to do otherwise.) Following the third such episode, patient was referred to neurology due to significant concern about second-impact syndrome. While no gray matter changes in the cingulate gyrus or white matter hyperintensities were noted on magnetic resonance imaging, given history and known risk factors neurology has recommended MRI to be repeated every two years, and they are arranging for diffusion tensor imaging in the near future.
Allergic: Earlier this year, patient was again rushed to GCGH for what appeared to be severe anaphylaxis, with marked angioedema of the face and hands, and widespread urticaria. After administration of high-dose IV Solu-Medrol, patient’s angioedema resolved sufficiently for him to report “tripping into a bunch of weeds” while hiking, and he eventually left the emergency department against medical advice. On outpatient follow-up, patient was referred for urgent allergy testing given the severity of his reaction. Skin-prick testing was negative for all food allergies, but was markedly and instantly positive in reaction to all plant allergens, such that a dose of IM Decadron was administered by allergist in the office. Despite was appears to be an extraordinary hypersensitivity to phytochemicals, patient has had no further symptoms following the one episode.
Psychiatric: During most visits, patient displays a somewhat somber and flat affect. Numerous inquiries into his mood yield answers that it is “just fine,” followed by requests to change the topic of questioning. While dysthymia or frank depression is suspected (particularly considering patient’s voluntary participation in flagrantly harmful recreational activities), patient seems to have avoided any major depressive episodes. More worrisome was an episode about a year and a half ago, during which patient appeared to have a psychotic break. On arrival at GCGH, patient was found to be suffering from vivid, terrifying hallucinations, rendering him essentially incoherent and requiring high doses of both benzodiazepines and haloperidol to abate. After regaining consciousness several hours later, patient stated that the “stress of [his] job” had gotten to him. He vehemently refused evaluation by Arkham consulting psychiatrist, and eventually left the ED AMA.
Social History: Patient denies smoking, drinking or taking any illegal controlled substances. He resides with Mr. Grayson, reportedly without romantic involvement. Diet consists largely of meals prepared by private household cooking staff. He reports serially monogamous sexual relationships with female partners. When asked, he states that he “usually has proper equipment,” which is interpreted to mean that condoms are used for contraception and STI prevention.
Family History: Both parents deceased (homicide). Generally assumed to be non-contributory
Temp 98.7, HR 60, RR 12, BP 113/68
General – well-nourished, well-appearing adult male in NAD; alert, oriented, cooperative
Skin – confluent, symmetrical, faintly erythematous rash extending from anterior hairline onto malar region (“from the hazmat mask they make me wear when I visit the lab”); four linear, well-healed lacerations on left pectoral (“fencing accident”). Numerous ecchymotic areas in various stages of healing
HEENT – small area of firm edema on the left occiput, c/w contusion. PERRLA, EOMI. TMs grossly intact bilat. Nares patent. Oropharynx normal. Good dentition, with evidence of repaired trauma
Chest – CTAB
CV – RRR without murmur. Radial, femoral pulses +2/4
Abd – soft, NTND, no HSM, + BS x 4.
Ext – well-defined (borderline hypertrophic) musculature. Limited active ROM in shoulders, elbows, wrists, knees, ankles, consistent with healing contusion/sprain or overuse injuries in numerous joints. Normal tone, strength UE/LE bilat.
Neuro – CN 2-12 grossly intact. ? faint resting tremor. FTN intact, no dysdiadokinesia. DTR +2/4 at patella, Achilles. Gait normal. Refuses MMS exam (“I have an aversion to riddles.”)
Psych – well-groomed, pleasant and conversational. A & O x3. Affect somewhat flat (baseline, as stated above)
Assessment/Plan — 40-year-old male with complicated past medical history as noted. Generally normal exam, excepting the following:
Rash — Patient advised that mask seems to be causing an irritant rash, and advised him to have lab personnel fit him with another, less occlusive size.
Resting tremor — Given risk factors stated above, there is some concern about early Parkinsonism. Will contact patient’s neurologist to have next follow-up appointment moved up.
Joint stiffness — As with previous visits, patient was advised to consider recreational activities that carry less risk of ongoing physical injury, or at very least allow himself to heal fully from previous trauma before returning to participation. Given the apparently quite aggressive tendencies of patient’s MMA club, advised him that almost any other activity he might choose is likely to confer less risk of ongoing morbidity (or even mortality). Patient responded to this advice with his usual polite indifference.
Looking more globally, there is some concern that there is an underlying illness that accounts for some of patient’s extensive symptomatology. Discussed with patient that there may be some obscure syndrome that includes brittle bones, but also propensity for severe hypersensitivity, psychiatric symptoms and skin damage. Advised him that many journals publish reports of puzzling cases, which may allow other physicians to comment helpfully about treatments or diagnoses that might be pertinent. Patient politely but emphatically refuses consent for such publication at this time.
Advised patient to limit stress, continue with (hopefully more benign form of) physical activity, continue with healthy diet. Flu shot administered. Planned follow-up in one year, sooner as needed.
(Note to clerical staff — please exclude the following note if there are future record requests. An alternate explanation, more plausible than the histories associated with many of patient’s injuries, is a series of industrial mishaps. As head of Wayne Enterprises, patient presumably takes a very active role in the company’s various subsidiary R&D departments. These subsidiaries include biotech, chemical and numerous other firms that traffic in hazardous materials. One might infer that some of patient’s more extreme medical problems stem from exposure to these hazards while taking a hands-on approach to running his company. There are a few understandable reasons that patient might wish to keep the true nature of his injuries private, despite assurances of medical confidentiality given that leaks of this information might undermine confidence in his company’s governance or alternatively might jeopardize secret government contracts. While it is somewhat regrettable that patient does not feel comfortable revealing the true nature of these injuries and exposures, it is nevertheless understandable.)