The abdominal pain with negative workup who insists "something is wrong!"

[pootcarr]

two cases last night.

first 17 y/o female with 3 day history of eipgastric and LUQ pain. Worse when raise hands over head. Associated with nausea. Murphy negative, not food related.Vital signs normal. CBC, CMP, Lipase, UA, CT abd pelvis normal. Mother insisting something is horribly wrong with her daughter. they both start crying. How to gracefully handle this situation?

40 year old who comes to ED several times a month. female. Flank pain, intermittent, crampy, radiate to RLQ. same work up as above. negative. vitals look good. "Something is exploding in me we have to find out whats wrong!"

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[gutonc]

Haldol?

Kidding. Sort of.

 

[TooMuchResearch]

Tell her not to raise her hands over her head.

 

[xaelia]

SMA syndrome.

Refer out, regardless.

 

[dotcb]

"I have good news for you - we checked the internal organs of your abdomen and took a 3 dimensional x ray of them all. All of the tests were normal, so that's reassuring. Some problems, like severe muscle cramps from example, won't show up on any test. I'm sorry you're so uncomfortable, but it looks like it isn't anything dangerous right now. I'm going to let you go home with some medicine for your symptoms, and I'd like you to get re-checked by a doctor in the next 2 days if you're not improving. You should see your regular doctor, Urgent Care, or come back here if you have no other options."

 

[The White Coat Investor]

This is like 60% of my practice. You'd think I'd be good at it by now.

It's often complicated by significant, but not overwhelming narcotic use, so often difficult to distinguish from narcotic dependence/drug seeking behavior/narcotic hyperalgesia.

 

[Birdstrike]

In the 17-yr-old. Pelvic ultrasound? Torsion? Very unlikely, as it's upper abdominal pain, but I've seen weirder. Or CXR? Lower lobe pneumonia? Unlikely without resp symptoms, but you never know.

In the 40 yr old, like xaelia said, "Bowel ischemia"? Also, pelvic US? Torsed ovarian mass? Again, highly doubt it, but I've seen weirder.

Yes, "crazy" is common, but beware of the, "I know something is seriously wrong!" patient. The are likely to be wrong, but likely to be very, very pissed off (and therefore lawyer happy) if you blow them off, imply they're crazy, and then turn out to be wrong. Every once in a great while, one of these surprises you and turns out to be right, and you end up wrong and looking like a fool, as a result. Stay humble.

 

[MSmentor018]

wow, crying in the ER out of frustration. that's hardcore
was the mom some kind of health care provider ? I've seen some correlation with that
crps? ulcer? some artery spasm back there? pt's psych, mom's psych, who knows?
birdstrike's right, don't blow them off. work them up to the hilt, give them the results. have them f/u with their PMD.

 

[GeneralVeers]

I don't have a problem with these patients unless they start asking me for narcotics. At that point the conversation is over and they are discharged.

 

[future_dr_house]

A lot of this is making sure they have the next part of the plan. The conversation should be... I've done everything I have at my availability in the emergency room. I think you need a specialist who had access to more testing. You may need a scope or a fancy pull that takes images as it passes down or you may have motility issues. Non of this testing is available to me. That's why I want you to see dr. X. Always offer alternative and mention that keeping them
In the hospital will not speed up things. Then reiterate that you would keep them of you thought it would lead to a faster diagnosis. Then dc


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[Hair Police]

I often use the story of the blind men and the elephant to convey that we don't have the whole story now, but with this work up started, they can follow up to get the next piece of the puzzle. I also emphasize we are very good at finding emergencies but not always making a diagnosis (IIRC, we make the diagnosis in ~40% of all abdominal pain coming into the ED).

 

[gman33]

I try to talk about the potential disposition before any testing is done.
We are going to get test X. Many times we don't find anything with this test, but it will let us know that you don't have A,B,C.
This lets us know you don't need surgery today and it is safe to go home.

Having this discussion up front can make the d/c home later go more smoothly.

What I really hate is the signed out patient where none of this was done.
You go in to talk to the patient after everything is negative and the patient feels like their visit was a waste of timeand nothing was done.

How do you guys deal with these patients where you have to deal with patient satisfaction?
Do you admit them for pain meds, serial exams, specialist eval?
We don't have press ganey at the shops i work as a resident.
Attendings would likely d/c almost all these people home, no matter how pissed off.

 

[medic25]

I often use the story of the blind men and the elephant to convey that we don't have the whole story now, but with this work up started, they can follow up to get the next piece of the puzzle. I also emphasize we are very good at finding emergencies but not always making a diagnosis (IIRC, we make the diagnosis in ~40% of all abdominal pain coming into the ED).

I like the blind man and the elephant idea. I'll often tell patients that my main job is to tell them what they don't have. Once I've confirmed this (you don't need surgery, don't need antibiotics, etc.), it's up to their PCP/GI/GYN to continue the process.

 

[MSmentor018]

I try to talk about the potential disposition before any testing is done.
We are going to get test X. Many times we don't find anything with this test, but it will let us know that you don't have A,B,C.
This lets us know you don't need surgery today and it is safe to go home.

Having this discussion up front can make the d/c home later go more smoothly.

What I really hate is the signed out patient where none of this was done.
You go in to talk to the patient after everything is negative and the patient feels like their visit was a waste of timeand nothing was done.

How do you guys deal with these patients where you have to deal with patient satisfaction?
Do you admit them for pain meds, serial exams, specialist eval?
We don't have press ganey at the shops i work as a resident.
Attendings would likely d/c almost all these people home, no matter how pissed off.

yeah getting the ****ty sign out is never helpful. I just start from scratch and tell the pt just that. you're taking over the case, let's review what's been done and needs to be done, times, expectations, meds....etc.

you guys don't have some kind of pt satisfaction scoring? it's a bunch of BS but that's the monster we created and have to live with

when it all comes up neg. I do a lot of teaching and give them a game plan including giving them specific names/address/offices to follow up with, sometimes I'll call the consultant and get some advice/give a heads up (it's a small community shop) esp with those that feel "entitled" and didn't get what they expected. I go over every single aspect and give them all dx results and say by doing it here you shouldn't need to get billed for another one. if you're really want to do some press ganey petting you can always bedazzle them with a bedside u/s.

some people do warrant serial exams admission but i find most don't. if they don't light up the narcotics database, I don't mind a short course until they do follow up, otherwise I try not to give any. I tend to do follow up phone calls. I'd rather burn 10 min now than get hauled in the office for 30 by the ceo

 

[southerndoc]

Usually I tell patients their blood work and CT is negative (and describe everything I checked).

"Your white blood count doesn't show evidence of infection, your hemoglobin doesn't show you're anemic, your kidney function and electrolytes are normal, and your liver function tests and pancreas tests are normal. The CT scan doesn't show any bowel obstruction, appendicitis, problems with your kidneys, problem with your spleen, or problem with your pancreas.

I can see you're still in pain and you're still concerned. A CT scan is just one test, and just because it's normal doesn't mean something isn't wrong. There's nothing serious going on that would require you to stay in the hospital, but you need to see a specialist for additional workup. I'm going to prescribe some pain/nausea medication for you and refer you to a GI specialist for further workup."

That's my standard spill for ALL negative abdominal workups, and I rarely get anybody saying something is wrong and they need to be admitted after adopting that. When I would walk in saying "everything is normal" without elaborating further, I would get 5-10% of patients wanting admission or thinking something is wrong saying that I'm missing something.

 

[Rendar5]

Things we are not able to diagnose in the ED that can cause severe abdominal pain: gastritis, pud, endometriosis, most diarrheal/malabsorption illnesses, ibs, biliary dyskinesia, pain due to abdominal adhesions (it does happen) and just general dyspepsia. I'm sure ther'es more but that's what a couple seconds gives me.

In these cases where they insist that something is wrong, I tell them that I completely agree. I tell them we've ruled out life threatening illneses and some common illnesses, but what they have, while not immediately life threatening, does need to be figured out because theyr'e OBVIOUSLY in such great pain. Depending on sx's, I tell them the next step may include cameras in the butt, the stomach, or the insides (elap for endometriosis), maybe a HIDA scan, which the person I am referring to can help figure out. I also mention that there are plenty of other tests (celiac, malabsorption issues) that they can run and get results on a few das later, and the only ones we are able to run in the ED are those that can give me results in an hour or two. Third, I mention that sometimes, what it is may become more obvious given a few days and their doctor can figure it out given a look at the entire course of the illness. I make sure they understand they can come back if sx's get worse (I in fact tell them to, most don't but they appreciate the offer of a second look), but the person who may figure out this complex and difficult to figure out medical issue may be their dotor, or they may et lucky nad have whatever it is go away in a couple days and never come back to bug them.

 

[goodoldalky]

I've rarely had a case like that where something really is wrong. 70+ year old lady stopped her Coumadin for AF comes in with severe pain, soft belly, tachycardia. CT Angio of the abdomen stone cold normal, exam unchanged. I was pretty convinced something was still wrong and admitted her, Perfed an ulcer a couple hours later.

However that is rare and in almost all cases I don't think anything serious is wrong. The next test most of these patients need after their ED workup would be a scope if anything. I frequently tell patients they need this endoscopy to further evaluate, that we don't do those, and if they want to pursue it further, give them a GI referral.

 

[fahimaz7]

Usually I tell patients their blood work and CT is negative (and describe everything I checked).

"Your white blood count doesn't show evidence of infection, your hemoglobin doesn't show you're anemic, your kidney function and electrolytes are normal, and your liver function tests and pancreas tests are normal. The CT scan doesn't show any bowel obstruction, appendicitis, problems with your kidneys, problem with your spleen, or problem with your pancreas.

I can see you're still in pain and you're still concerned. A CT scan is just one test, and just because it's normal doesn't mean something isn't wrong. There's nothing serious going on that would require you to stay in the hospital, but you need to see a specialist for additional workup. I'm going to prescribe some pain/nausea medication for you and refer you to a GI specialist for further workup."

That's my standard spill for ALL negative abdominal workups, and I rarely get anybody saying something is wrong and they need to be admitted after adopting that. When I would walk in saying "everything is normal" without elaborating further, I would get 5-10% of patients wanting admission or thinking something is wrong saying that I'm missing something.

So what he's saying is I may have appendicitis? At leas that's what happens to me half the time when I try to talk down one of these guys.

 

[DoctorMedic]

I regularly tell my frequent fliers that "I'm happy to do some standard testing for your pain and screen for any emergencies, but I can't give you any narcotic pain medications unless I find something wrong as you have been here numerous times for the same complaint and this is now a chronic pain problem." Most are actually ok with that, the one's that arent' usually walk out pretty quickly.

Anyone see anything wrong with this approach? Is this an EMTALA violation for telling them I won't give narcotic medications off the bat?

 

[southerndoc]

I regularly tell my frequent fliers that "I'm happy to do some standard testing for your pain and screen for any emergencies, but I can't give you any narcotic pain medications unless I find something wrong as you have been here numerous times for the same complaint and this is now a chronic pain problem." Most are actually ok with that, the one's that arent' usually walk out pretty quickly.

Anyone see anything wrong with this approach? Is this an EMTALA violation for telling them I won't give narcotic medications off the bat?

EMTALA requires you to perform a screening exam and to stabilize any medical issues that are life threatening. It does not require that you medicate with narcotics. Even the Joint Commission considers an ice pack as a form of pain management.

 

[MSmentor018]

I always say this "lets try to find the root of the problem instead of just covering them up with narcotics" I warn them about the side effects of long term use and tell them I am not going to put them at risk and make things worse, let's try other meds/therapies. except for pt complaints i've never heard of lawsuits or any violations from not giving narcotics but I've read pt's suing b/c we got them "hooked or dependent" or side effects from chronic use.
we have a chronic pain mgt policy, unless you've got something terminal or active cancer. there's a card we hand out that politely says no