Identification: Mr. S. Claus is a 2000 y.o. Nordic male brought in by reindeer after an unwitnessed fall.
History of Present Illness: Patient is new to our local hospital system, having previously received care at NPMG (North Pole Medical Group) prior to losing his insurance due to his seasonal employment status. Records are sparse and obtained from a non-interoperable EMR system (EPIC: Elvish Polar Information Cache).
Apparently the patient was in his usual state of chronic disease until the Night Before Christmas, when he was found down in egg nog by a local family at the bottom of their fireplace. Local firefighters were called to extract him and he was found to be quite agitated and combative, vomiting coffee grounds into a red stocking hanging on the fireplace. After 5mg of haldol IM he was subdued and taken by sleigh to the ED. Several reindeer presumed to be his were tranquilized at the scene by animal control authorities and will be quarantined for further testing. Half eaten cookies were found by the chimney and paramedics report a fingerstick glucose of 932 at the scene.
In the emergency room he is found to be an extremely poor historian, answering most questions inappropriately with “Ho Ho Ho!” followed by paroxysms of wheezing.
No family contacts are available, although his wallet contains a picture of what appears to be an obese, rather hirsute male, labeled only “Mrs. Claus.”
He denies chest pain, dizziness, rectal bleeding, and his own existence. Please see detailed med student note for further history.
ROS: Unable to obtain as pt responds only with, “You are on the naughty list, little boy!” and subsequently vomits bright red blood.
Allergies: tylenol, codeine, “all that stuff that doesn’t start with a D”, saline, O2
Past Medical History: per coworkers at the North Pole (via AT&T Elvish translator): Sleep Apnea, Coronary Artery Disease, Diabetes Mellitus, Congestive Heart Failure (diastolic dysfunction), Chronic Hep C, Erectile Dysfunction, Gout, Bipolar.
Meds: Mistletoe 2 sprigs q6hrs, Fruitcake 1 loaf daily, Figgy Pudding QHS PRN angst, Oxycontin 40mg BID, Viagra.
Social History: Married, self-employed as a toy deliveryman. Denies tobacco, but CAGE questions positive for likely egg nog abuse and huffing. + recent travel to Africa on business (Ebola protocol activated in ER)
Family History: Adopted by elves.
Physical Exam: Hypothermic, BMI 40+, vitals otherwise stable. Appears older than stated age.
Morbidly obese, inappropriately jolly man in no acute distress
Obvious rhinophyma, poor dentition, breath smells of mistletoe and smoked salmon
Diffuse wheezes bilaterally with “wrapping paper” rales at the bases
Heart is enlarged with displaced PMI, “Jingle Bells” murmur at the apex
Abdomen is obese, benign with well-healed Christmas-tree shaped scar. “Tinkling” bowel sounds.
Extremities show 3+ pitting edema to the thighs with holly-shaped rash on shins
Neuro: “Stocking” pattern neuropathy of feet/legs
Rectal exam: + yule log
Genitourinary: soot-covered testicles. Tree is untrimmed.
ECG: rapid atrial fibrillation with Osborn waves
Elderly Nordic male with acute on chronic everything.
- Acute Egg Nog Intoxication with Psychosis. Lipoid aspiration pneumonia. Likely Salmonella. Subsequent episode, W32.4AD
- Suspected Borderline Personality Disorder (views children as either all good or all bad). Prior records suggest “doctor shopping” and mistletoe-seeking behavior.
- Chronic Obstructive Pulmonary Disease secondary to longstanding chimney smoke exposure, with likely additional component of fibrosis and restriction — “St. Nick’s Triad”
- Obesity Hypoventilation Syndrome, complicated by non-compliance with BiPAP and lack of available power outlets in his sled, and further worsened by fixed belief in “alternative” medical treatments such as candy cane extract and elf-magic.
- Lyme Disease secondary to recurrent reindeer tick exposure.
- Deep Venous Thrombosis with risk factor of prolonged air travel, obesity, trauma from recurrent chimney intrusion, Christmas Factor overproduction.
- Atrial Fibrillation: “Holiday Heart.”
- Chronic Testicular Inflammation secondary to chimney soot-induced dermatitis, W29.3DX Jingle Balls, Acute, Bilateral, Initial episode
- Syndrome X(mas): insulin resistance, hypertension, central obesity, and elevated triglycerides that occur in conjunction with an epidemic retail Christmas decoration outbreak, occurring earlier and earlier every year (symptoms now start as early as the day after Thanksgiving).
- Diabetic hyperosmolar state with dehydration secondary to dietary noncompliance.
1. Ho Ho Hospice.
Total 70 minutes floor time, >50% coordination and counseling.
Until next time, merry Christmas to all, and to all a good call night!