An Unusual Presentation

Several months ago I went to see a patient in my ED with the Chief Complaint: Altered Mental Status. Fairly common complaint in the ED.

On entering the room was a mid-60’s nice, polite lady and her two daughters, who were visibly nervous about being there.

What seems to be the problem?

“You have to understand that our mom is not a cookies-and-milk grandma. She’s not, she’s actually a piss-and-vinegar type. Usually she’s a little mean, but the last week or so she’s been the nicest little old lady in the world. Something is wrong with our mom.”

So, you think there’s something wrong with your mom because now she’s being nice?

“Very much so. This isn’t her usual self.”

After a pretty unremarkable rest of the history and exam (except for a remarkably nice and polite patient) I had to talk myself into doing a workup, but I did. I ordered blood and urine tests, and a CT scan of the head.

A CT which showed a marble-sized frontal lobe brain tumor with some surrounding edema. A tumor in the region of the brain having to do with personality. I found out why she was nice. Her daughters were actually relieved, not that mom had a tumor but that they hadn’t been wasting everyones’ time.

Amazing thing, being too nice. It took a brain tumor to make her that way.


  1. Oh my. This reminds me of “someone I know and love”. I used to tell my children, if they ever catch me acting like “someone I know and love”, to remind me that I swore never to act like “someone I know and love”.

  2. Congrats to you for taking the family seriously enough to order the definitive test. I’m thinking not everyone would have.

    Only slightly related (to the title of your post, unusual presentation): there were a few times in the OR when I said, after completing some gawdawful case were nothing was clear and the situation seemed pretty grim, “Well, that was a classic presentation of whatever the f**k that was.”

  3. hehehe what an extrange presentation! so being a nice guy is bad!

  4. It’s so hard to realize whether it’s the patient or the family who has the problem. in this case it was clearly the patient

  5. Goatwhacker says:

    Well I’ll piss in everybody’s cornflakes a little here and ask what the hell was she doing in an ER?

  6. Bonticou says:

    Yes, congratulations to you for taking the family seriously and ordering that CT scan. Took me nearly four months to get help for my husband, who woke up nasty as hell and verbally abusive one Sunday morning. No one took me seriously, bc. he also had a low Na count – they’d keep him a day or to until it got up to “low” and send him home. His primary physician take on this was that “This is a MENTAL problem. I’m a physician, and I treat PHYSICAL problems,” and shooed us out the door. (That guy is on my bad list and no longer my husband’s MD.)

    Finally I got him on tape stating that he’d like to take a 45 and shoot me (he doesn’t have any gun, let alone a 45) and the police took it seriously enough to make the hospital do some tests. Small areas of damage in the frontal and temporal lobes. 18 months later, he’s mostly back to normal and Mr. Nasty has made no repeat appearances – but those four months sure were hell. Sure wish we’d found an MD like you in the first ER episode.

  7. Christopher Henry says:

    Recalls the Phineas Gage tamping rod accident, the 1848 story used in neuroanatomy to illustrate the early understanding of frontal lobe function and the consequences of frontal lobe injury.

  8. She must have really been a humdinger of a nasty person. Its pretty bad when your so mean that your kids suspect you have a brain tumor when you act nicely. Not only suspect but believe it to be an emergent situation. And they were right! heh..

  9. This sounds like a happier ending than most. Often it is a chronically debilitated septic nursing home patient sent in with a chief complaint of ALOC (“no longer moaning and groaning”). A couple of days of IV fluid and antibiotics and they get sent back to the nursing home moaning and groaning.

    On another bend I think a similar thing happened to Lance Armstrong. His brain tumors destroyed the part of the brain that feels pain, fatigue, and lactic acid!

  10. Good catch there!

    I once took a kid to the pedi because he wanted to play at 2am. Kid had slept through the night from BIRTH. Really. They thought I was nuts until they looked in his ears.

  11. I had a case very much like that a few years ago… only it was the nurses, who knew the family, who called my attention to the personality change. The spouse was too startled by how nice things had been around the house to complain at good fortune.

    (That patient had a small CVA, not a tumor; but in the same area you describe.)

    Invites melancholy, doesn’t it?


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