Atypical presentations

[Utswong]

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Long time lurker here, always enjoyed reading the clinical threads here. Here's my first stab at stimulating some more interesting discussion.

As I progress through residency what I've come to realize is that some of the most difficult patients to manage are not those with a barn-door STEMI or obvious polytrauma, but rather those who walk into your cubicle with some vague chief complaint but just don't look right, and yet after further investigation turn out to have something much more sinister brewing underneath. Just two examples from the last month:

59M with good past health walks into urgent care section of the ED complaining of pleuritic chest pain and SOB on exertion. Looks well and walks unaided, not in distress. Sats 98% on room air. Sinus tachycardia 120 with normal BP. Chest, heart, abdominal, and neurological examinations unremarkable. ECG: sinus tachycardia with ?S1Q3 pattern. Imp: to R/O subclinical PE. Bedside echo and DVT scans unremarkable. However first cbc came back with a platelet count of 7, Hb of 7.5! elevated bilirubin, ldh, and urate as well. Admitted to medicine and now being worked up by haematology. Can't say that pancytopenia is the first thing that comes to mind when I see a patient with a cc of chest pain.....

94F with left hemiarthroplasty performed last month for #NOF, uneventful postop course. Came in three weeks later with a dislocated left hip. Closed reduction performed uneventfully and admitted to ortho for further management. The chief surgeon smells something fishy as the stability tested intraoperatively was very good, and so he proceeds to perform a hip aspiration that subsequently yields...gram positive cocci... Someone now decides to auscultate more carefully and actually picks up the new onset MR murmur...echo confirms a huge 1.7cm vegetation on the mitral valve. Can't say that I've seen infective endocarditis presenting with a hip dislocation before....

Some of the best attendings I've met are those who seem to have a sixth sense about them, a clinical sense that allows them to pick up that something was wrong with these patients with atypical presentations. I for one have always learned a lot from these kinds of cases (more so than from cookie cutter cases with obvious diagnoses and dispositions). Anyone else have similar cases to share?

 

[Arcan57]

The key to these cases is not so much being Osler or “lucky”, as recognizing something doesn’t fit the pattern you’d expect and knowing what your tests do and don’t rule out. Just had a slip and fall with chronic back pain having some weakness in his right leg associated with pain in hip and knee. Plain films negative. Checked CT pelvis because weakness (still antigravity when he made an effort) was a little out of proportion to pain. Looking for occult femoral neck fracture or pubic rami fx. Found lymphoma.

Your first case was unusual (maybe TTP from what you’re describing) but this is a guy that was not and never should have been a fast track pt. He’s got CP and SOB and an abnormal HR. He’s going to get labs 10/10 times. I find it helpful to focus my thinking on the negative space of the workout. I don’t really care about anemia,NSTEMI, large PTX, ginormous tumor, or Boerhave’s as a cause for the patient’s CP because my work up is going to catch 100% of them. It’s the dissection or PE I spend time thinking about. Same with belly pain. If they look great, I’m thinking what are the chances they have something I’d miss and care about if I don’t lab or scan. If I scan, what pathology would I miss that doesn’t show up on a scan (testicular torsion being the board favorite for that). If you think like that, you’d be surprised how many of these “lucky” diagnoses you pick up.

 

[Vermicious Knid]

Long time lurker here, always enjoyed reading the clinical threads here. Here's my first stab at stimulating some more interesting discussion.

As I progress through residency what I've come to realize is that some of the most difficult patients to manage are not those with a barn-door STEMI or obvious polytrauma, but rather those who walk into your cubicle with some vague chief complaint but just don't look right, and yet after further investigation turn out to have something much more sinister brewing underneath. Just two examples from the last month:

59M with good past health walks into urgent care section of the ED complaining of pleuritic chest pain and SOB on exertion. Looks well and walks unaided, not in distress. Sats 98% on room air. Sinus tachycardia 120 with normal BP. Chest, heart, abdominal, and neurological examinations unremarkable. ECG: sinus tachycardia with ?S1Q3 pattern. Imp: to R/O subclinical PE. Bedside echo and DVT scans unremarkable. However first cbc came back with a platelet count of 7, Hb of 7.5! elevated bilirubin, ldh, and urate as well. Admitted to medicine and now being worked up by haematology. Can't say that pancytopenia is the first thing that comes to mind when I see a patient with a cc of chest pain.....

94F with left hemiarthroplasty performed last month for #NOF, uneventful postop course. Came in three weeks later with a dislocated left hip. Closed reduction performed uneventfully and admitted to ortho for further management. The chief surgeon smells something fishy as the stability tested intraoperatively was very good, and so he proceeds to perform a hip aspiration that subsequently yields...gram positive cocci... Someone now decides to auscultate more carefully and actually picks up the new onset MR murmur...echo confirms a huge 1.7cm vegetation on the mitral valve. Can't say that I've seen infective endocarditis presenting with a hip dislocation before....

Some of the best attendings I've met are those who seem to have a sixth sense about them, a clinical sense that allows them to pick up that something was wrong with these patients with atypical presentations. I for one have always learned a lot from these kinds of cases (more so than from cookie cutter cases with obvious diagnoses and dispositions). Anyone else have similar cases to share?

This is the strangest part of the case. Where did the ortho get the stethoscope from?

 

[deleted109597]

Sick vs not sick. If you try to look for super rare presentations of things, your positive predictive value is going to be almost zero. Use bayesian probabilities.
Or scan everybody and be that guy/girl. Don't be that guy/girl.

 

[deleted859535]

The key to these cases is not so much being Osler or “lucky”, as recognizing something doesn’t fit the pattern you’d expect and knowing what your tests do and don’t rule out. Just had a slip and fall with chronic back pain having some weakness in his right leg associated with pain in hip and knee. Plain films negative. Checked CT pelvis because weakness (still antigravity when he made an effort) was a little out of proportion to pain. Looking for occult femoral neck fracture or pubic rami fx. Found lymphoma.

Your first case was unusual (maybe TTP from what you’re describing) but this is a guy that was not and never should have been a fast track pt. He’s got CP and SOB and an abnormal HR. He’s going to get labs 10/10 times. I find it helpful to focus my thinking on the negative space of the workout. I don’t really care about anemia,NSTEMI, large PTX, ginormous tumor, or Boerhave’s as a cause for the patient’s CP because my work up is going to catch 100% of them. It’s the dissection or PE I spend time thinking about. Same with belly pain. If they look great, I’m thinking what are the chances they have something I’d miss and care about if I don’t lab or scan. If I scan, what pathology would I miss that doesn’t show up on a scan (testicular torsion being the board favorite for that). If you think like that, you’d be surprised how many of these “lucky” diagnoses you pick up.

This right here.

I do the exact same thing. Focus on the "negative space" -- as was said, for people like your number 1, you did the right thing chasing PE. You had to. And you know that academically, if you have to create a monster ddx with med students around a table, hematologic malignancies / severe anemia could cause much of the presentation. But why mentally masturbate about it? Routine labs that every decent EP worth his/her salt will order will catch a lot of the "other" things. That's practical medicine for you when you have 12 other patients to care for simultaneously.

The dissection comment is very apropos. I don't waste my time flagellating about a weird MI when I know the presentation is inconsistent and my workup will catch it anyway, and I plan on admitting for chest pain workup in the end. I spend my time justifying why I'm not CTing them or ordering such-and-such. And document accordingly.

An immeasurable part of medicine is heuristic in nature. This is also part of why there is no substitute for the sheer volume that comes with med school and much more importantly, residency.

It's like the difference between someone with the flu and someone who's clearly flu-like but, damn, something's not quite right... because they have AML.

As for your hip case: I'd be willing to bet there was some other detail that led to the arthrocentesis, nice catch regardless.

 

[wholeheartedly]

This is the strangest part of the case. Where did the ortho get the stethoscope from?

My money is on the ID doc...

 

[wamcp]

Long time lurker here, always enjoyed reading the clinical threads here. Here's my first stab at stimulating some more interesting discussion.

As I progress through residency what I've come to realize is that some of the most difficult patients to manage are not those with a barn-door STEMI or obvious polytrauma, but rather those who walk into your cubicle with some vague chief complaint but just don't look right, and yet after further investigation turn out to have something much more sinister brewing underneath. Just two examples from the last month:

59M with good past health walks into urgent care section of the ED complaining of pleuritic chest pain and SOB on exertion. Looks well and walks unaided, not in distress. Sats 98% on room air. Sinus tachycardia 120 with normal BP. Chest, heart, abdominal, and neurological examinations unremarkable. ECG: sinus tachycardia with ?S1Q3 pattern. Imp: to R/O subclinical PE. Bedside echo and DVT scans unremarkable. However first cbc came back with a platelet count of 7, Hb of 7.5! elevated bilirubin, ldh, and urate as well. Admitted to medicine and now being worked up by haematology. Can't say that pancytopenia is the first thing that comes to mind when I see a patient with a cc of chest pain.....

94F with left hemiarthroplasty performed last month for #NOF, uneventful postop course. Came in three weeks later with a dislocated left hip. Closed reduction performed uneventfully and admitted to ortho for further management. The chief surgeon smells something fishy as the stability tested intraoperatively was very good, and so he proceeds to perform a hip aspiration that subsequently yields...gram positive cocci... Someone now decides to auscultate more carefully and actually picks up the new onset MR murmur...echo confirms a huge 1.7cm vegetation on the mitral valve. Can't say that I've seen infective endocarditis presenting with a hip dislocation before....

Some of the best attendings I've met are those who seem to have a sixth sense about them, a clinical sense that allows them to pick up that something was wrong with these patients with atypical presentations. I for one have always learned a lot from these kinds of cases (more so than from cookie cutter cases with obvious diagnoses and dispositions). Anyone else have similar cases to share?

So uh did you get cta and rule out pe for the chest pain pt anyway? Because ttp can cause thrombosis/clots and risk is also still high with hematologic malignancies....

 

[TooMuchResearch]

Never underestimate the power of getting lucky. And remember, if you miss something weird, they'll probably bounce back and we'll get another shot.

 

[RoyBasch]

Never underestimate the power of getting lucky. And remember, if you miss something weird, they'll probably bounce back and we'll get another shot.

This is why bouncebacks need to be worked up aggressively however. You can still miss on your second shot if you don't do anything new or different.

 

[fahimaz7]

Recently had a 50 y/o male withe flank pain and hematuria come in for evaluation. Sudden onset, severe, radiated to right testicle. Normal aorta on bedside u/s. He was a self-pay and I had to talk him into a CT scan as it was his "first" stone. CT showed a renal mass, which didn't make since as that should cause painless hematuria. Did a delayed CT with contrast and found his renal mass had thrombosed his entire ureter leading to severe hydronephrosis, thus the presentation like a kidney stone.
Dx: RCC
Dispo: University center

Same week:
~70 y/o male with hematuria and dysuria. + burning. No anticoagulants. UA with microscopy + UTI (nitrate, LE, blood). No CVAT and non-toxic. Seen the next day in f/u with urology for cystoscopy for bladder CA evaluation. Prior to their study she ordered a CT to look for bladder cancer and found...
DX: RCC


It's a landmine out there.

 

[turkeyjerky]

Recently had a 50 y/o male withe flank pain and hematuria come in for evaluation. Sudden onset, severe, radiated to right testicle. Normal aorta on bedside u/s. He was a self-pay and I had to talk him into a CT scan as it was his "first" stone. CT showed a renal mass, which didn't make since as that should cause painless hematuria. Did a delayed CT with contrast and found his renal mass had thrombosed his entire ureter leading to severe hydronephrosis, thus the presentation like a kidney stone.
Dx: RCC
Dispo: University center

Same week:
~70 y/o male with hematuria and dysuria. + burning. No anticoagulants. UA with microscopy + UTI (nitrate, LE, blood). No CVAT and non-toxic. Seen the next day in f/u with urology for cystoscopy for bladder CA evaluation. Prior to their study she ordered a CT to look for bladder cancer and found...
DX: RCC


It's a landmine out there.

Not really sure why you seem to care so much about diagnosing cancer, especially in a system where you can evidently get next day speciality followup.

Yeah, cancer sucks. That doesn't make it an emergency...

 

[thegenius]

Recently had a 50 y/o male withe flank pain and hematuria come in for evaluation. Sudden onset, severe, radiated to right testicle. Normal aorta on bedside u/s. He was a self-pay and I had to talk him into a CT scan as it was his "first" stone. CT showed a renal mass, which didn't make since as that should cause painless hematuria. Did a delayed CT with contrast and found his renal mass had thrombosed his entire ureter leading to severe hydronephrosis, thus the presentation like a kidney stone.
Dx: RCC
Dispo: University center

Same week:
~70 y/o male with hematuria and dysuria. + burning. No anticoagulants. UA with microscopy + UTI (nitrate, LE, blood). No CVAT and non-toxic. Seen the next day in f/u with urology for cystoscopy for bladder CA evaluation. Prior to their study she ordered a CT to look for bladder cancer and found...
DX: RCC


It's a landmine out there.

On that first case, the initial CT should have shown severe hydronephrosis (of unclear cause). Along with the renal mass that probably didn't directly cause the hydronephrosis, in the absense of a stone would probably lead one to suggest the mass was causing the hydronephrosis somehow. It's admittedly cool to see a CT report, though, that the ureter was thrombosed!

 

[GonnaBeADoc2222]

Someone brought up imaging before.

In residency, I always tried to not get the CT.

As an attending, I almost always get the CT. Obviously I'm not CTing the 25 yo with epigastric pain or the 28yo who bumped their head, but most people >50yo with belly pain are getting the CT.

The threat of medmal definitely contributes to this, however I've found some really weird stuff out there.

 

[GonnaBeADoc2222]

Not really sure why you seem to care so much about diagnosing cancer, especially in a system where you can evidently get next day speciality followup.

Yeah, cancer sucks. That doesn't make it an emergency...

You need more empathy. Pretend that this were you or your family member.

True, it's not (always) an emergency (sometimes it is - case #2 above is certainly an emergency). But it's worthwhile to make this dx in the ED. I've diagnosed multiple cases of cancer in people with vague symptoms that were repeatedly blown off by whatever person they were seeing outpatient. The 52 yo F with 4 months of abdominal "bloating", weight loss, and decreased appetite is 100% getting a CT from me to evaluate for ovarian CA. I don't care about the"system" - I care about doing the right thing.

 

[thegenius]

True, it's not (always) an emergency (sometimes it is - case #2 above is certainly an emergency). But it's worthwhile to make this dx in the ED. I've diagnosed multiple cases of cancer in people with vague symptoms that were repeatedly blown off by whatever person they were seeing outpatient. The 52 yo F with 4 months of abdominal "bloating", weight loss, and decreased appetite is 100% getting a CT from me to evaluate for ovarian CA. I don't care about the"system" - I care about doing the right thing.

Makes you wonder what primary care doctors are for? They just manage HTN and HL? LOL

 

[RoyBasch]

Someone brought up imaging before.

In residency, I always tried to not get the CT.

As an attending, I almost always get the CT. Obviously I'm not CTing the 25 yo with epigastric pain or the 28yo who bumped their head, but most people >50yo with belly pain are getting the CT.

The threat of medmal definitely contributes to this, however I've found some really weird stuff out there.

I practice both in academics and in the community, and the longer my community practice goes on the more I agree with this sentiment.

It's always interesting to me when I'm back with the residents this idea is so foreign to them. They seem to view CTing patients besides trauma activations as a huge defeat.

The CT yield in pt's over 50 for almost any complaint/indication who are not the typical academic/county hospital malingerers is astonishingly high.

 

[GonnaBeADoc2222]

I practice both in academics and in the community, and the longer my community practice goes on the more I agree with this sentiment.

It's always interesting to me when I'm back with the residents this idea is so foreign to them. They seem to view CTing patients besides trauma activations as a huge defeat.

The CT yield in pt's over 50 for almost any complaint/indication who are not the typical academic/county hospital malingerers is astonishingly high.

I partially blame the EM-FOAM world that seems to always say that if you don't bedside u/s everyone to "spare them radiation", ever order tPA, or ever order tamifu, you are a terrible physician.

 

[turkeyjerky]

You need more empathy. Pretend that this were you or your family member.

True, it's not (always) an emergency (sometimes it is - case #2 above is certainly an emergency). But it's worthwhile to make this dx in the ED. I've diagnosed multiple cases of cancer in people with vague symptoms that were repeatedly blown off by whatever person they were seeing outpatient. The 52 yo F with 4 months of abdominal "bloating", weight loss, and decreased appetite is 100% getting a CT from me to evaluate for ovarian CA. I don't care about the"system" - I care about doing the right thing.

I think you mean that the 1st case was an emergency—I agree. The 2nd case was obviously, definitively not an emergency.

Resource utilization aside, I don’t think the ER is the place for malignancy workups. It’s not my training and the environment is not conducive to it. Nor do I believe most patients benefit from a focus on it. I’m shocked at how often I admit someone for an ‘expedited work up’ after finding a suspicious mass on imaging, only to find the hospitality discharged them first thing in the morning with directions to call their PMD.

I don’t see how patients without acute or severe symptoms benefit from a malignancy diagnosis in the ED vs one a few days later as an outpatient by a specialist. Most of the time they get harmed by an (unnecessary) night in the hospital, and being given a life altering diagnosis without the counseling that should go along with that.

Do you order mammograms for patients who come in w/ breast complaints? Urine cytology and CT urograms for hematuria?

When you order that stat CT of the chest, do you understand that the reading radiologist likely isn’t thoracic trained and you may be doing a disservice to the patient as they’ll get a subpar read?

I’m not sure what the best test to evaluate for ovarian cancer is, maybe it’s a CT scan, maybe it’s an US followed by an MRI.

Anyway this is an unnecessary digression. What I meant in my earlier post is that the ‘landmines’ I’m worried about are not malignancies—they’re the cases of occult sepsis, vascular catastrophes, and so on. I wouldn’t consider it a miss if I refer someone for follow up and they’re found to have cancer.

 

[GonnaBeADoc2222]

I think you mean that the 1st case was an emergency—I agree. The 2nd case was obviously, definitively not an emergency.

Resource utilization aside, I don’t think the ER is the place for malignancy workups. It’s not my training and the environment is not conducive to it. Nor do I believe most patients benefit from a focus on it. I’m shocked at how often I admit someone for an ‘expedited work up’ after finding a suspicious mass on imaging, only to find the hospitality discharged them first thing in the morning with directions to call their PMD.

I don’t see how patients without acute or severe symptoms benefit from a malignancy diagnosis in the ED vs one a few days later as an outpatient by a specialist. Most of the time they get harmed by an (unnecessary) night in the hospital, and being given a life altering diagnosis without the counseling that should go along with that.

Do you order mammograms for patients who come in w/ breast complaints? Urine cytology and CT urograms for hematuria?

When you order that stat CT of the chest, do you understand that the reading radiologist likely isn’t thoracic trained and you may be doing a disservice to the patient as they’ll get a subpar read?

I’m not sure what the best test to evaluate for ovarian cancer is, maybe it’s a CT scan, maybe it’s an US followed by an MRI.

Anyway this is an unnecessary digression. What I meant in my earlier post is that the ‘landmines’ I’m worried about are not malignancies—they’re the cases of occult sepsis, vascular catastrophes, and so on. I wouldn’t consider it a miss if I refer someone for follow up and they’re found to have cancer.

You're right. Admission for discovering a malignancy absent an acute presentation like sepsis or a mechanical complication is rarely beneficial and these patients do better with outpatient management. There are some cancers however that should likely always be admitted and treated expeditiously (acute leukemia, testicular CA, etc).

However, just because we're not completely working them up for their malignancy, doesn't mean that we shouldn't be diagnosing it. It's not like we are ordering abdominal MRIs and PET studies to stage these people. Yes, if someone comes in with a cough x 6 months, looking cachectic and chronically ill, I am ordering a CT chest. What are you going to say: "Meh, follow up with your PCP"? What's it to you to follow up on one more study and get the patient started on the path they need to be on?

 

[RoyBasch]

I partially blame the EM-FOAM world that seems to always say that if you don't bedside u/s everyone to "spare them radiation", ever order tPA, or ever order tamifu, you are a terrible physician.

These guys practice in a different world of sovereign immunity, minimal patient satisfaction goals and metrics, etc.

Academically it is correct to say that most malignancies are not emergencies and the patient can follow up. I would emphasize that It is NOT sub standard of care to not work these patients up.

However, I work in the real world, a lot of patients do not follow up, particularly if they don't have an actual diagnosis.

I think when you tell a patient, "This CT scan shows a highly suspicious mass that is likely cancer, here is your follow up." You will have a very different percentage actually following through than when you tell somebody "Hematuria could be serious, you need to follow up."

 

[thegenius]

I partially blame the EM-FOAM world that seems to always say that if you don't bedside u/s everyone to "spare them radiation", ever order tPA, or ever order tamifu, you are a terrible physician.

EM-FOAM folks appear to operate in a vaccuum. I wonder what kind of ERs they work in:

- acetaminophen and NSAIDs is good enough for almost all pain. HAHAHAHAH I have patients who say, in not so many words, "If I don't get dilaudid 2 mg IV q10 mins PRN pain x4 doses I'm going to sue you and your family and you will be miserable. Gimme my drugs."

- bedside ultrasound everything. Think you have a dislocated intercostal joint? Just ultrasound it!!!! Think you have testicular torsion? US it yourself and then convince the Urologist that your ultrasonography skills are superior to the tech's and just GET HERE NOW AND FIX THIS. Think your person has TTP-HUS? Just ultrasound it!!! There are differential flow characteristics through medium-sized arteries found in the mesentery that can indicate, with low specificity, that you are a dumb-dumb for even considering trying this.

- Get your patient follow-up tomorrow. Yea right. Their follow-up tomorrow is the ED.

- If you combine 6 different scoring systems, and give each one different weights, you don't have to run any test at all in the ED and you can safely discharge them. With this model, you can rule out MI, dissection, PE, testicular torsion, stroke, hypotension, sepsis, trauma, and poly-substance abuse. Just make sure you give them acetaminophen 650 mg PO before discharge. Because it's good enough for their pain. COMING SOON: ruling out real suicidal ideation by an additional screening tool validated in 9 south pacific islands as reported in Australasia Lancet peer-reviewed journal.

 

[thegenius]

I think when you tell a patient, "This CT scan shows a highly suspicious mass that is likely cancer, here is your follow up." You will have a very different percentage actually following through than when you tell somebody "Hematuria could be serious, you need to follow up."

AGREE! Here is a real vignette. I was at a residency where one of the instructors was sued (prior to my arrival), successfully, for not telling a young patient with stable hematochezia that he needs to get it checked out urgently as an outpatient. The patient waited for ~6 months, then had more bleeding, workup showed stage 4 colon cancer and pt died soon after. The argument was that the ER attending didn't say "One of the things your rectal bleeding could be is colon cancer, so don't ignore this." The plantiff's attorney argued that if the ER attending said "this could be cancer", he would have gone to the doctor sooner, thus possibly avoiding death.



So I actually tell patients things like "that mass could be, among other things, cancer. Don't ignore it. Get it checked out." And I tell them that I'm purposely trying to scare them so they don't ignore this. I also use the same tactic when I get real young people, in their 20's and 30's who come in with some minor complaint and have a screening BP of 200/130. I tell them there is a virtual guarantee, 100%, that in 10 years you will be either 1) on dialysis, 2) have a big stroke, or 3) have a big heart attack.



Query: If you tell someone "hey your car is making a strange sound, better get that checked out." or if you say "hey, your car is making a strange sound, and I'm confident that it means there is a 50% chance its going to blow up in 1 week", which statement do you think will make people more likely to get it checked out?

 

[deleted859535]

AGREE! Here is a real vignette. I was at a residency where one of the instructors was sued (prior to my arrival), successfully, for not telling a young patient with stable hematochezia that he needs to get it checked out urgently as an outpatient. The patient waited for ~6 months, then had more bleeding, workup showed stage 4 colon cancer and pt died soon after. The argument was that the ER attending didn't say "One of the things your rectal bleeding could be is colon cancer, so don't ignore this." The plantiff's attorney argued that if the ER attending said "this could be cancer", he would have gone to the doctor sooner, thus possibly avoiding death.



So I actually tell patients things like "that mass could be, among other things, cancer. Don't ignore it. Get it checked out." And I tell them that I'm purposely trying to scare them so they don't ignore this. I also use the same tactic when I get real young people, in their 20's and 30's who come in with some minor complaint and have a screening BP of 200/130. I tell them there is a virtual guarantee, 100%, that in 10 years you will be either 1) on dialysis, 2) have a big stroke, or 3) have a big heart attack.



Query: If you tell someone "hey your car is making a strange sound, better get that checked out." or if you say "hey, your car is making a strange sound, and I'm confident that it means there is a 50% chance its going to blow up in 1 week", which statement do you think will make people more likely to get it checked out?

Two questions.

1: what state?

2: was there any imaging or abnormal labs in that ED visit / do you know if the usual aftercare info was provided for follow-up that lists possibilities?

 

[deleted109597]

EM-FOAM folks appear to operate in a vaccuum. I wonder what kind of ERs they work in:

- acetaminophen and NSAIDs is good enough for almost all pain. HAHAHAHAH I have patients who say, in not so many words, "If I don't get dilaudid 2 mg IV q10 mins PRN pain x4 doses I'm going to sue you and your family and you will be miserable. Gimme my drugs."

- bedside ultrasound everything. Think you have a dislocated intercostal joint? Just ultrasound it!!!! Think you have testicular torsion? US it yourself and then convince the Urologist that your ultrasonography skills are superior to the tech's and just GET HERE NOW AND FIX THIS. Think your person has TTP-HUS? Just ultrasound it!!! There are differential flow characteristics through medium-sized arteries found in the mesentery that can indicate, with low specificity, that you are a dumb-dumb for even considering trying this.

- Get your patient follow-up tomorrow. Yea right. Their follow-up tomorrow is the ED.

- If you combine 6 different scoring systems, and give each one different weights, you don't have to run any test at all in the ED and you can safely discharge them. With this model, you can rule out MI, dissection, PE, testicular torsion, stroke, hypotension, sepsis, trauma, and poly-substance abuse. Just make sure you give them acetaminophen 650 mg PO before discharge. Because it's good enough for their pain. COMING SOON: ruling out real suicidal ideation by an additional screening tool validated in 9 south pacific islands as reported in Australasia Lancet peer-reviewed journal.

I think your perception of FOAM is skewed.
Honestly, I don't care if they want dilaudid. I don't have it. I never will, because it has minimal benefit to patients over other drugs, but huge potential harm. And, if you actually look at the studies for pain, tylenol and motrin do work about 90% as well as opioids. The biggest group of people they don't work in are those already addicted. If they need opioids, morphine and fentanyl are perfectly adequate.
I don't ultrasound anything but retinas and central lines in the US. Overseas, where CTs and Xrays are much, much harder to get, I do a lot more.
Scoring systems are clinical decision instruments, not rules. If you're on the fence, use one. If you already think they have something, the scoring system should not convince you they don't. That's not how it's designed. Similarly, if you don't think they have it, don't do it either. See also: d-dimer.
OTOH, people follow Amal Mattu (who is the opposite of FOAM) like he's a deity, and he says literally everyone with chest pain should be admitted. Not sure what I would do by 730am once every bed was an admitted chest pain patient, but hey, whatever.

 

[RoyBasch]

AGREE! Here is a real vignette...

I do tell patients when they have these incidentelomas that they could be cancer. I do specifically use the word "CANCER" and not "malignancy." I subsequently document in my note something like:

"Lung nodule incidentally noted on CT chest was explicitly discussed with the patient and his family. Explained this mass could represent an early cancer among other possibilities. The need for follow up repeat surveillance imaging coordinated by his primary physician Dr. Smith to evaluate for growth or change within 6-12 months was discussed."

Related question for those of you in academics: do your programs emphasize the importance of counseling patients on incidental findings? I am only part time staff at an academic program (work majority in the community) but every time I talk to residents about discussing and documenting the conversation regarding incidental findings the resident invariably rolls their eyes, lets out a sharp exhalation, and indicates they think I am the most conservative idiot physician they have ever worked with.

 

[Arcan57]

I do tell patients when they have these incidentelomas that they could be cancer. I do specifically use the word "CANCER" and not "malignancy." I subsequently document in my note something like:

"Lung nodule incidentally noted on CT chest was explicitly discussed with the patient and his family. Explained this mass could represent an early cancer among other possibilities. The need for follow up repeat surveillance imaging coordinated by his primary physician Dr. Smith to evaluate for growth or change within 6-12 months was discussed."

Related question for those of you in academics: do your programs emphasize the importance of counseling patients on incidental findings? I am only part time staff at an academic program (work majority in the community) but every time I talk to residents about discussing and documenting the conversation regarding incidental findings the resident invariably rolls their eyes, lets out a sharp exhalation, and indicates they think I am the most conservative idiot physician they have ever worked with.

Tell their eyes to STFU. Arranging follow-up for abnormal findings is basic blocking and tackling. Hand them a copy of the report, say "This is what I'm talking about, show it to your doc", done. These are the same docs that are going to get hosed by a radiology read that has unexpected emergent pathology that's buried in a wall of text they can't be bothered to scan through.

 

[deleted859535]

I do tell patients when they have these incidentelomas that they could be cancer. I do specifically use the word "CANCER" and not "malignancy." I subsequently document in my note something like:

"Lung nodule incidentally noted on CT chest was explicitly discussed with the patient and his family. Explained this mass could represent an early cancer among other possibilities. The need for follow up repeat surveillance imaging coordinated by his primary physician Dr. Smith to evaluate for growth or change within 6-12 months was discussed."

Related question for those of you in academics: do your programs emphasize the importance of counseling patients on incidental findings? I am only part time staff at an academic program (work majority in the community) but every time I talk to residents about discussing and documenting the conversation regarding incidental findings the resident invariably rolls their eyes, lets out a sharp exhalation, and indicates they think I am the most conservative idiot physician they have ever worked with.

Easy for residents to huff and puff about something like this until they're the ones primarily responsible for the liability of the visit. All of a sudden, things make sense. Weird!

 

[thegenius]

Two questions.

1: what state?

2: was there any imaging or abnormal labs in that ED visit / do you know if the usual aftercare info was provided for follow-up that lists possibilities?

NY

I don't know anything else about the case w.r.t. labs, imaging. My guess is whatever workup was done did not suggest an emergency at that initial time in the ED. Just speculation.

 

[thegenius]

I think your perception of FOAM is skewed. (1)
Honestly, I don't care if they want dilaudid. I don't have it. (2) I never will, because it has minimal benefit to patients over other drugs, but huge potential harm. And, if you actually look at the studies for pain, tylenol and motrin do work about 90% as well as opioids. The biggest group of people they don't work in are those already addicted. If they need opioids, morphine and fentanyl are perfectly adequate.
I don't ultrasound anything but retinas and central lines in the US. Overseas, where CTs and Xrays are much, much harder to get, I do a lot more.
Scoring systems are clinical decision instruments, not rules. If you're on the fence, use one. If you already think they have something, the scoring system should not convince you they don't. That's not how it's designed. Similarly, if you don't think they have it, don't do it either. See also: d-dimer.
OTOH, people follow Amal Mattu (who is the opposite of FOAM) like he's a deity, and he says literally everyone with chest pain should be admitted. Not sure what I would do by 730am once every bed was an admitted chest pain patient, but hey, whatever.

1. Perhaps
2. What do you mean you don't have it? Your hospital doesn't have it on formulary?

 

[deleted109597]

1. Perhaps
2. What do you mean you don't have it? Your hospital doesn't have it on formulary?

I own a freestanding. I made the formulary. I specifically chose to leave dilaudid off for this reason.