What a stroke
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A 64 year old man, who lived alone, was found collapsed one morning by his daughter. He responded only to painful stimuli and seemed to have weakness of the left side of his body. He was brought by ambulance to the accident and emergency department, the paramedics alerting the department that they were bringing a patient with stroke. On arrival at the department, the patient's Glasgow coma scale was 10/15. He was not moving the left side of his body, although tone was normal in both arm and leg and power could not be assessed because of his low Glasgow coma scale. He had equivocal plantar responses and pinpoint pupils. We diagnosed pontine haemorrhage and arranged for computed tomography as we assumed that he had weakness of the left side of the body.
While waiting for the computed tomography, we thought that the pinpoint pupils could be an indication of an opiate overdose. We therefore gave the patient 400 μg of naloxone intravenously, which improved his Glasgow coma scale. Within 10 minutes he was sitting up and talking to us. He had no weakness of the left side of the body, but he complained of severe abdominal pain. It became clear that he had had sudden onset of abdominal pain nearly 12 hours before being brought to hospital and had taken 25 tablets of co-proxamol to relieve this pain. He was prescribed co-proxamol tablets for pain in his knees from osteoarthritis.
On further examination, he showed guarding in the upper abdomen with some rebound tenderness. To our astonishment, an x ray of his chest and abdomen showed free air under the diaphragm. He confirmed that he had had a duodenal ulcer in the past. A diagnosis of perforated duodenal ulcer was made, and he was successfully treated by surgery.
We learnt to always exclude an overdose of opiates as the cause of pinpoint pupils in all our patients. We were unable to explain the patient's lack of use of the left side of the body on presentation.
JOUR
Ansari, Umair
Crampton, James
2005
BMJ
331
7515
513
0959-8138
10.1136/bmj.331.7515.513
697
