Snippets
A 69 year old patient presented for arthroscopic knee surgery. Her husband, a doctor with severe Parkinson's disease, had been mistakenly resuscitated against his wishes and died three weeks later in the intensive care unit. After this event the patient had written a living will to ensure that no such confusion would occur in her case. A living will should be sufficient in making clear a patient's wishes, but in order to further clarify her instructions, she had also had the words "Do Not Resuscitate" tattooed on her left chest wall. The arthroscopy was completed without adverse event under regional anaesthesia.
C McCartney assistant professor,
Glen McGuire assistant professor, department of anesthesia and pain management, Toronto Western Hospital, Toronto, Canada
Two weeks after a systemic illness with fever and diarrhoea, a 57 year old man developed this appearance. His eyeballs turned upwards when he attempted to close his eyes. Bilateral Bell's phenomenon is found in myasthenia gravis, sarcoidosis, bilateral Bell's palsies, congenital facial diplegia, some rare forms of muscular dystrophy, and motor neurone disease. Rarely, it can be the presenting feature of Guillain-Barré syndrome, which this man went on to develop. He responded well to intravenous immunoglobulins.
J Smith, locum registrar,
B Henderson, consultant, department of neurology, Pinderfields Hospital, Wakefield WF1 4D
Purple urine bag syndrome was first reported in the 1970s, but it has long been recognised anecdotally in elderly patients. The purple discolouration of urine and bag is most often reported to be due to the indirubin dissolved in plastic and indigo crystals in the urine, which coat the bag surface. Urinary indican (indoxyl sulphate) is derived from metabolised tryptophan in the gut. Urinary organisms such as proteus, providencia, and klebsiella with indoxyl sulphatase activity metabolise indican to produce indigo, particularly in alkaline urine. Bile acids or steroidal conjugates can also cause purple discolouration. Apart from alarming visitors and medical staff, the colour may be of no clinical importance.
J E Clague, consultant, D McDowell, consultant, department of medicine for the elderly, University Hospital Aintree,
Liverpool L9 7AL
studentBMJ 2001;09:261-304 August ISSN 0966-6494
