10. Headache
A week after introduction to Neurology, intern Goldberg walks through the swinging doors of the operating suite. The neurology training program wants its intern to get a wide view. So he assists at operations in addition to his usual work.
Dr Goldberg first saw Joe Provenzano 4 days before he saw Joe's bare brain. He asked What is your chief complaint? and got the terse Headache! Mr Provenzano, a well-put together 30-year-old, points right finger to back of head and makes a face.
Goldberg's physical exam does not show anything but when he presents the case on rounds, Dr Stan embarrasses him by asking "Did you look in the eyes?" and when Goldberg says No, Dr Stan says "From the chief complaint the important diagnosis is brain tumor. And your deduction should be: If so, he should show a sign of increased brain pressure in the eyes. And you should have examined them? Well, let's do it."
Dr Stan takes out his eye scope and, with Goldberg, walks to Joe's bed and, after introducing himself and explaining, he bends over the friendly patient, who is lying face up, and looks into the back of the left eye. Finishing, he hands the scope to Goldberg. After a minute, Goldberg exclaims "Papilledema!"and the patient worriedly asks "Whut in hell izzat?" to which Goldberg replies "Just a little swelling."
Afterwards, Dr Stan says "Irving. I should have told you: Always be aware of your words and actions. But, anyway, you saw the swelling, a sure sign of an expanding tumor inside the skull."
"Gee, Dr Pelc, I really missed that one, didn't I?"
"That's why you're an intern, Irving; to learn by missing and having it pointed out. Now you know. What next?"
"A pneumoencephalogram?”
"Good, Irving, we - I mean you - will do it tomorrow at 1 PM."
"Me? I never did a pneumo before?"
"Don't worry. I'll be there and the radiologist too."
A pneumo is injecting air into the free space in the brain by needle in back of head between the cranial bones. It is scary but harmless. A series of x-rays then show the air in the ventricles - the central brain cavities - and also the air gets into the rim beneath the skull, so it outlines the brain shape externally and the ventricles internally. In Mr Joe Provenzano's case it shows a small brain tumor blocking the 3rd ventricle - and causing back-up of fluid inside the brain and the headaches. Left untreated it would destroy the brain in another month.
"A tumor of the pineal gland," says Dr Stan after putting the x-ray views up on screen. I'll show it to Leo Davidoff. You will assist him, at the operating table.
That is why intern Goldberg now reports to Chief Nurse Sheila in OR suite. For next, click 13.11 At the Operating Table
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