Patient BW, DOB 2/16/1971
Patient: Wayne, Bruce
DOB: 2/16/1971
Occupation: Industrialist
Insurance: Self-pay
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
Physical exam:
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.)
This was eminantly worthy of the front page. I cannot praise it enough.Report
An emphatic +1Report
+2?Report
Most excellent! =DReport
This is awesome.Report
I’ve re-read this four times (interrupted each time), and a different line is my favorite every time.
Currently the fav is:“I have an aversion to riddles.”Report
Right now I’m voting for “Both parents deceased (homicide). Generally assumed to be non-contributory” as my favourite.Report
Mine too.Report
Likewise.Report
I like: “He reports serially monogamous sexual relationships with female partners.”Report
Just wonderful. The suggestion that Dick’s abusing Bruce made me laugh (that sounds very wrong now that I say it).Report
This post linked by Glenn Reynolds. Instalanche!
WD, Dr. Saunders.
http://pjmedia.com/instapundit/131648/
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Nice H&P. As a pathologist, I can only DREAM of getting such a detailed Hx lol.Report
“Patient’s robust stature is not consistent with osteogenesis imperfecta”Report
Not only is this post awesome, but I think I can say with very little doubt that hit #3 million is going to be on this post. And this pleases me to no end.Report
Actually, I can’t let this stand at “awesome” or “wow”. Rufus, this is really fantastic, and amazingly creative. I’m a little curious, how much of this is you being a DC comics fan, and how much of it was you doing research? In either case, it was hard not to think as I was reading it, “This is going be picked up sometime soon by other sites, and it is going to explode.”Report
Rufus?Report
Oops. Russell, obviously.Report
I think you meant me? Anyhow, I wouldn’t have been able to write this without Jaybird. (The whole thing was his idea, anyhow.) He gave me some indispensable tips about what to include, and the rest was from my own knowledge of the comics and movies.Report
My contributions consisted of “well, Bane broke his back but I’m sure that everything else has been broken at least once!”
This was all Russell.Report
Came here from a link on io9.com and very glad I did – as a long-time comics fan I shall take great pleasure in waving this in front of a couple of doctors I know for their amusement 🙂Report
Great job, but one thing that kept bugging me was the doctor’s confusion over Bruce’s relationship with Dick. Dick is technically his son. Why would it be odd that one of his 3 adopted sons or one biological son would accompany him to the hospital? Suggesting that he might be romantically involved is kinda pervy on the doctor’s part.Report
I know both Dick and Tim were abortive who’s the 3rd? (Didn’t think Jason was around long enough to get adopted)Report
His son, by Talia al Ghul (Ra’s daughter), Damian. The newest Robin.Report
Pat said 3 adopted or one biological, Damian was of course the biological, that still leaves one moreReport
Jason Todd (Current Red Hood) is the 3rd.Report
Actually, Jason was the first Robin to be adopted despite being the second one. It wasn’t until much later that Bruce adopted Dick and Tim (after his father was killed), and then discovered Damien was his biological son. /NERDReport
This is absolutely wonderful. I’m so happy io9 linked to your site! I had to look up some of the medical terminology, which made this even more of a treat. Thank you!Report
This has been linked by numerous other locations.
From the comments here, my favorite:
“That is a forgery based on pure speculation. The simple fact of the matter is that Mr. Wayne has enjoyed an uninterrupted and long period of excellent health – to which state of affairs several boards of directors can attest. I read (sorry, lost the link) a press release on monday in which he was forthcoming about the fact that he often seeks routine medical care for a man his age from some very private and elite physicians, including several offshore — but as he reasonably explained this is precisely because conventional domestic medical care providers are unable to protect the privacy of a man of his stature. The medical records leaked here are certainly a forgery for the simple reason that no such records can exist, for Mr. Wayne has never sought or received treatment from these people. Indeed, in this forgery, you can see that not only does the conventional system fail to protect his privacy but it will even make stuff up if he won’t cooperate.
Next week after arrangements are finalized Mr. Wayne will release key excerpts of his authentic medical records as they are maintained by his personal physicians in Switzerland and Denmark. These will include many X-ray images that lay to rest rumors of “(> 20) orthopedic injuries.”
These forgeries are particularly nefarious and targeted because, as far as Wayne’s organizations can determine, some of the physicians involved may have at one time believed that they actually provided service to Mr. Wayne when, in fact, they have never met. Wayne Enterprises is working with these doctors in an attempt to identify and prosecute whatever Bruce Wayne impersonator obtained treatment under a false identity.”
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You’re front page on IO9, Doc 🙂Report
I really can’t even begin to describe how incredibly tickled I am by all of this.Report
It’s always fun as a blogger when someone else picks up your stuff.Report
well, well! isn’t this just fantastic? I will take this into my work @ Ace comics tomorrow, and wave it in the face of some of the biggest Batman fans I know……Excellent work!Report
This is already the seventh most popular post (page views) this year, according to our local stats database.
I will bet dollars to donuts it beats out everything except possibly The Second Date Story by tomorrow morning.Report
If it doesn’t become the number one post all time by tomorrow morning, it will be soon. I said earlier, this is the post that will push us over 3 million.Report
In fact, I just looked at the site stats. This post is going to push us over 3 million in the next few hours. This makes me a little giddy.Report
We’ve passed it!Report
If ever there was a day that I regret we don’t all live in the same city, this would be that day. It feels like we should be calling each other right now figuring out which bar we’re going to go get a couple of rounds at, you know?Report
I’m still sick.
I’m having medicinal scotch tonight, though, that’s for sure.Report
I think it goes without saying that the first round would be on me.Report
My dear Doc, well done sir!Report
At least now I know which contribution of mine might be worthy of a LOOG anthology.Report
Dude, if this were the 90’s, you could have published this in Wizard.Report
Actually, now that I think about it, doesn’t JAMA have goofy stuff on the very last page of every issue?
This could *EASILY* be submitted for that.
I’m serious.Report
Up to number four.
See, Russell? We *told* you it was front page material 🙂Report
Third now:
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Bravo, Bravo. Amazingly good!Report
For giggles, anyone wanna take a crack at how I came up with Dick Grayson’s phone number?Report
Oh! Just got it! BOY WONDer!!!!
This post just keeps getting more and more brilliant>Report
Hee.Report
That’s awesome! 😀Report
Holy crap, forget about the page views, Doc. Have you noticed the number on the Facebook thingy?Report
He’s also been Farked.Report
“Farked.” Talk to me like I’m over 40…?Report
Fark is a “news” aggregator site that specializes in posting “news” links that are far more appropriate for “The Z100 Marty and Nugget Morning Zoo WEIRD NEWZ!” segment than, say, CNN or even Fox. (They are worth visiting for the really, really funny headlines alone.)
Doc Saunders made the Geek page.Report
Don’t forget about being slashdotted.Report
I hadn’t seen that one yet!
Awesome.Report
Really? I seem to have missed it, myself.Report
Fantastic stuff. See, this place just keeps getting better and better. All the traffic we’re getting from this post – think of all the ad revenue! Oh the riches…
Actually, I’ve been at a conference the past few days and didn’t see this until io9 emailed me about it, but it’s quite brilliant and deserving of all the attention its getting. Bravo, Russell.Report
That must have been surreal and awesome.Report
That was fantastic. We are testing a new EHR system at my office and have to make several dummy accounts, I made one for James Bond, though not nearly as detailed or funny as this, you Sir are brilliant.Report
Submit the James Bond one as a guest post 🙂Report
One would assume there would be an STI or two reported.Report
Social History: It done falled off.Report
“Die Another Day” beat you to it, unfortunately.Report
Teehee. This is great. The details on the history are astounding.Report
imagine what would happen if the same doctor also xrayed dick greysonReport
I thought the TSA were the only ones who X-rayed dick?
(bahDOOMP! thanks folks I’m here all week!)Report
I keep re-reading this article, it makes me chuckle. Bravo! Also :
Patient has denied being the victim of domestic abuse by Mr. Grayson following indirect and direct questioning on numerous occasions.
This was comedy gold! I keep imagining how mortified Bruce must have felt when his doctor brought that up. Haha.Report
Ehehe. That was fantastic. Thank you.Report
“Family History: Both parents deceased (homicide). Generally assumed to be non-contributory”
Absolutely the best line.Report
holy cow, I’m older than batman! best thing I’ve read in weeks, doc. kudos!Report
yes bruce wayne is the most “human” superheroes of all,he can fall asleep,he needs to eat,he doesn’t has any superpower ability…but the thing is ..he has a lot of toys !the combination of his gadget and his brain is just great !thats why he could outsmart DARKSEID …Report
Really good.Report
I can’t praise this enough fellas. This is absolutely fantastic. Extremely well detailed in every aspect (and funny too!). The part that Grayson might be abusing Bruce was the best part by far.Report
BP is only reported with an odd number (113) if taken by machine, however the fact that both the heart and respiration rate are divisible by 4 suggest a manual approach. Change BP to 114/68 and it’s perfect.Report
Just wanted to chime in, Dr. Saunders, that this was a huge hit on the medical school student forums at UCSD – not only is this awesome, but you are also teaching us how to write medical reports properly with abbreviations! Thanks!Report
I can’t begin to tell you how much that delights me. Best of luck to you and your colleagues!Report
I’m a second career nursing student, and this is something I’ve forwarded to some fellow students as a study aid, to remember direct quotes from the patient! Thank you.
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I teach in a practical nursing program and a student emailed me this link! I loved it so much that I plan on using it with my beginning students tonight to talk about how to read an H&P!
I’m not even a huge comic book fan, but I got it!
Thanks for the laugh!Report
This now officially out-views “The Second Date Story”. That’s not even counting the views on the subblog.
The good doctor owes everybody a round!Report
Seriously, if there were a way to make this happen, you better believe I would buy everyone who showed up at the designated venue a drink. (Also Megan McArdle, who seems like an exceptionally good sport.) I am so pleased that people enjoyed something I wrote (mostly during my son’s naptime last Sunday).
Now, of course, I’m thinking about sequels.Report
All of the candidates I’m coming up with as suggestions unfortunately end with, “Uh, wait, this should be an autopsy, because they totally wouldn’t have survived that last movie…”Report
Just thinking out loud, Batman worked because the whole “olympic-level athlete” thing was pulled back to earth by the “merely human” thing along with the positively brilliant discussions of the leftovers from the various injuries that he’d be likely to have survived (and the little easter eggs that readers found when they knew the REAL story behind injuries).
What other superheroes would be interesting to read about for this many paragraphs? I certainly can’t think of any. Daredevil, Mr. Fantastic, Superman, Wonder Woman, Ben Grimm, The Flash, Wolverine… just trying to imagine the stories they’d give their doctor would be interesting after they came from the hands of our Dr. Saunders, but none thrill me the way that the thought of a Batman one would.
Now, Carmen mentioned James Bond and that has possibilities… additionally, characters such as Rocky might be interesting… but the whole template of “human, all too human” belongs to Batman.Report
I have something in mind, which I’ve bounced off the Better Half. It’s a variation on the theme. I’ll mull it over for a little more time, then will probably see what select readers (that is, probably the two of you) think before I post it.Report
Even if it isn’t the success this one was, it will still be useful as a teaching aid, and apparently your post has been co-opted for that purpose by two medical educators.
That in and of itself must feel pretty dang zawzome.Report
brilliant, so so so perfect, thanks you so much for this. First fav line was
“significant medical problems are associated with odd or incongruous explanations”
then these
“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.”
but to end w/ this
“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”
is when you became my hero.
#thanksdoesnotcutit
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*applause* This is absolutely brilliant!Report
I’m a bit late to the party, I know, but I just had to comment.
I routinely do a lot of “faux professional reports” for various projects. I have a lot of difficulty coming up with good references for me to base my work off of more often than not; for example, it’s pretty hard for me to find after-action reports for modern clandestine operations of the type that I occasionally write about. Often times, I have no idea where to even begin looking.
Now, at last, I have a point of reference for one of those frustrating moments. Something that, while I may not be able to emulate perfectly due to a lack of education, I can now be able to say to myself “Oh, a medical history for this character would fit in perfectly here. I know right where to go to figure out the format for that!”
Or, in less flowery prose, thank you! Thank you so much! You’re going to save me so much time of staring blankly at the screen and wondering how I thought this was a good idea! Not only does this seem very professional, but the fact that I enjoyed reading it makes it that much easier for me to get an idea as to how it works! I owe you one! (Can I fit another exclamation point into this paragraph? Yes I can!)Report
My favorite line:
“well-defined (borderline hypertrophic) musculature.”Report
The only other hero I could think of that fits the “all too human” category would be Indiana Jones, and with the supernatural/classified/no one would believe this if I told them aspect of his adventures, it might make an interesting medical report.
Excellent and funny read, keep up the good work!
That’ll be $.02, please 🙂
ChrisReport
Hi! I was wondering if you ever did any follow-ups with other characters?Report
Hello Jane! The answer is “yes”. He had one follow-up post that took a different tack.Report