Not Your Garden Variety Urgent Care Patients

Patient #1
He's an 88-yr-old man brought in by his adult son.  For the past 2 days, the patient has been feeling dizzy and, curiously, leaning to the left (physically, not politically).  "I feel like I'm on a ship," he tells me, holding onto the wall as he ambulates.  His neurological exam is completely normal, except that he really does lean extraordinarily to his left side, even while perched on the exam table.  There is no facial asymmetry, no hemiparesis, no aphasia, no slurred speech, no visual impairment.  I send him to the ER because I'm worried he has had a stroke.  His head CT was normal, but sure enough his MRI revealed evidence of a stroke in the posterior cerebellum.

Patient #2
A 76-yr-old man comes in and tells me his heart rate has been in the 30s for the past 4 days.  He generally feels fine, although occasionally he experiences mild transient shortness of breath.  An ECG reveals bradycardia at 35 bpm with complete atrioventricular block.  I explain to him that his heart is beating very slowly because the upper portion of his heart is not communicating well with the lower portion of his heart.  Although he looks remarkably well, he will probably need a pacemaker.  He waves goodbye to me as the paramedics wheel him out on a gurney, smiling and winking as he clutches the Mario Puzo novel he's been reading.  He gets a pacemaker inserted within hours of arriving in the ED.

Patient #3
A 53-yr-old man accompanied by his wife is here for what he calls a rash.  "I thought it was an allergic reaction to something, " he says, and his wife adds, "We've been putting warm compresses on it and hoping it would go away."  The left side of his face from his forehead to his cheek is remarkably red and swollen, and multiple pustules with yellowish discharge are visible.  His left upper eyelid is so swollen he can barely open his eye which is exuding an endless stream of pus.  His left sclera is erythematous, he has pain with eye movements, and there is slight proptosis.  I sent him to the ER out of concern for herpes zoster ophthalmicus vs orbital cellulitis.  On CT, an "incidental" brain tumor was found--and by incidental, they meant a 7.8 cm meningioma which had been miraculously asymptomatic.  The patient got IV acyclovir, IV ceftriaxone, and a 12-hour craniotomy.