A 45 yo female arrived by ambulance with her two sons with a chief complaint "she's not right." I arrived into the room with 3 med students and began my assessment. First, I asked the sons about her medical history and the events leading up to her "not being right." The sons stated that she has no medical problems, takes no medicines, and was last seen acting normal earlier that day. When they arrived home later that evening, the bedroom door was locked, and their mother was screaming for help. They broke down the door to get in and found her in bed screaming for help with her nightgown on.There were no signs of a trauma or blood anywhere. They then called "911" for help.
I examined the patient and started with the head and shouted to the medical students who were helping document. "Ears clear, pupils reactive 3-->2 but sluggish, mouth clear." When I examined her head, I felt around the top of skull and felt something squishy. I then moved over the light and tried to get a better look. Unfortunately her hair was covering the area. I shouted, "Okay I feel a large skull defect but no bleeding or bone fragments." The last time I felt something like that was during neuroanatomy in med school.... but surely it couldn't be brain! I then poked it a couple more times and she screamed "Ouch, ouch!" both times.
I screamed out, "Well guys, this feels like brain!" The entire room feel silent and the medical students thought I was crazy. One med student said "but there's no blood or bone fragments or trauma anywhere on the patient." I said, "I know, it doesn't make sense."
I ordered a CT scan of her brain and sure enough, she had a large skull defect with brain coming out! She had a bacterial brain abscess which ate her skull from the inside which explained why no bone fragments were found. When the abscess got big enough, it ruptured causing her to faint. She then fell exactly on the spot of the abscess and popped her brain! She ended up returning to work without any long term complications.