Consults- Memorable/Dismal/Ridiculous/Unique

[dpmd]

I had to Google “hearing aid dome” thinking maybe it was some kind of cast of debris that forms from wearing hearing aids or something.

I was not expecting it to be part of the hearing aid itself. Yeah. Super yikes.

Oh I totally assumed.it was like a cast of the hearing aid in earwax

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[DOVinciRobot]

Today in House M.D. "Mysteries of the Ear"

60ish gentleman with history of hearing loss and hearing aids noted worsened left sided hearing, pressure, and discomfort x 1 month.

Since then, his PCP, audiologist, and his wife (retired RN) have all looked in his ear.

His PCP told him "I don't think it is an ear infection, but let's try some antibiotics anyway just to be sure". This did not help.

He got a hearing test which was not sent with his referral.

He then got MRIs of his brain/IACs and orbits (??!?!?!), as well as a MRA of his head and neck for some reason. All normal.

Today I saw him and noted a HUGE FREAKING HEARING AID DOME in his left ear canal which I pulled out. Hooray, he is cured!

What the literal hell, people

But did they try Ancef?

 

[OtoHNS]

Well, you would have to look in the ear to see that and that’s not something you can expect a primary care provider to do.

Incidentally the MRI didn’t mention an occluded canal?

MRI report only mentioned that the mastoids were aerated. No mention of the EAC at all. I only had the report, not the images, so not sure how easy it was to see.

 

[maxxor]

MRI report only mentioned that the mastoids were aerated. No mention of the EAC at all. I only had the report, not the images, so not sure how easy it was to see.

MRI can be deceiving with non-organic obstructions cuz of artifact.

 

[Pir8DeacDoc]

But did they try Ancef?

For us it would be Amoxicillin or if urgent care is feeling very feisty Augmentin.
Maybe a side order of ciprodex drops cause it has a super power of traversing an intact drum and fixing middle ear issues- which aren't actually present anyway.

But it's very clear someone is lost and throwing crap at the wall when patient comes in on oral antibiotics and drops. That combination just isn't needed. Or is very, very rarely needed. Good times

 

[HighPriest]

For us it would be Amoxicillin or if urgent care is feeling very feisty Augmentin.
Maybe a side order of ciprodex drops cause it has a super power of traversing an intact drum and fixing middle ear issues- which aren't actually present anyway.

But it's very clear someone is lost and throwing crap at the wall when patient comes in on oral antibiotics and drops. That combination just isn't needed. Or is very, very rarely needed. Good times

z-packs for us. I think they just keep a garbage bin full of z-packs and just hand you one when you check in at UC. And they would never give drops because they don’t know if there’s a hole in the eardrum!!!!

And also, you have to look in the ear to know, so that’s a non-starter.

And for the non-ENT, having a hole is not a contraindication, if anything it works better.

 

[HighPriest]

MRI can be deceiving with non-organic obstructions cuz of artifact.

They’re usually silicone. But I suppose it might not visualize well.

 

[maxxor]

They’re usually silicone. But I suppose it might not visualize well.

The biggest “gotcha” a neurorad pulled on me was an MR Face that had what looked like clear sinuses. She pulled out the same day CT which had totally impacted hyperattenuating mucus. Some of the material in chronic inspissated mucus or fungal colonization can cause MR signal loss. Her lesson was “don’t call clear sinuses on MR. You can be faked out”.

Basically, unless it looks like soft tissue up in there, I’m not commenting on the absence of that kind of stuff in MR.

CT would more likely show.

 

[HighPriest]

The biggest “gotcha” a neurorad pulled on me was an MR Face that had what looked like clear sinuses. She pulled out the same day CT which had totally impacted hyperattenuating mucus. Some of the material in chronic inspissated mucus or fungal colonization can cause MR signal loss. Her lesson was “don’t call clear sinuses on MR. You can be faked out”.

Basically, unless it looks like soft tissue up in there, I’m not commenting on the absence of that kind of stuff in MR.

CT would more likely show.

So you’re saying the PcP should have ordered a CT and THAT is the only way to know there’s a FB in the ear canal. . I gotchu.

 

[maxxor]

So you’re saying the PcP should have ordered a CT and THAT is the only way to know there’s a FB in the ear canal. . I gotchu.

Ya man. Send em straight for the temporal bone CT (which I never read as I am not a neurorad 😂)

 

[Neopolymath]

The biggest “gotcha” a neurorad pulled on me was an MR Face that had what looked like clear sinuses. She pulled out the same day CT which had totally impacted hyperattenuating mucus. Some of the material in chronic inspissated mucus or fungal colonization can cause MR signal loss. Her lesson was “don’t call clear sinuses on MR. You can be faked out”.

Basically, unless it looks like soft tissue up in there, I’m not commenting on the absence of that kind of stuff in MR.

CT would more likely show.

Classic. You look at T2 and it looks fine and never look at them on any other sequence. It's a great case conference case.

 

[eyeeye_captain]

Weekend special:

Answering service: Hi, Outside Hospital in nearish city is calling you for a consult.
Me: …ok, why? Is it one of our patients?
AS: No, they have someone in their ICU with fungus in their blood they want you to see today. They say you’re on call.
Me: …let them know I don’t have privileges at their hospital and I can’t see the patient.

Never mind that the rate of ocular infection in fungemia is <1% even in an ICU setting and both national bodies of ophtho and ID have said there’s no reason to screen asymptomatic patients. I guess this particular hospital feels they can use Google as their call roster.

 

[HighPriest]

Weekend special:

Answering service: Hi, Outside Hospital in nearish city is calling you for a consult.
Me: …ok, why? Is it one of our patients?
AS: No, they have someone in their ICU with fungus in their blood they want you to see today. They say you’re on call.
Me: …let them know I don’t have privileges at their hospital and I can’t see the patient.

Never mind that the rate of ocular infection in fungemia is <1% even in an ICU setting and both national bodies of ophtho and ID have said there’s no reason to screen asymptomatic patients. I guess this particular hospital feels they can use Google as their call roster.

Who should we consult about this patient?

Attending:

Although I know how this probably went:

Patient has been having some vision problems.

Ok. When did that start?

Four years ago.

Better call someone….you know, just to be sure.

 

[eyeeye_captain]

Weekend fun again. Got a text message from an area code that is an 11 hour drive away about a patient with an area code 14 hours away in a different direction.

Also, we don’t have a text service.

Good luck, friend. *shrug*

 

[LucidSplash]

Someone walked into our clinic on Friday off the street looking to be seen by a doctor. This is in a building attached to a hospital but not somewhere you wander into accidentally. You can’t get to it from the main hospital without a badge through a back door. And you pass other specialties on your way to our office from the patient entrance.

Patient “hit his hand with something a few days ago” and was in a lot of pain and hand bruised and swollen. Friend saw it and suggested patient get it looked at by a doctor. Somehow patient (never been seen in our office before) picked our office.

Please note our office is vascular surgery and general surgery. No trauma.

MAs came back asking if the vascular NP could fit a walk in onto her schedule. I was sitting nearby and asked questions.

Patient redirected to the ED attached to the hospital for his broken hand. 🤷🏼‍♀️

 

[OtoHNS]

This was a long time ago, but my office once got a call at 4:55 pm on a Thursday from a Mom of a young adult son (never before seen by me). She stated that we had to see her son the next day and immediately take his tonsils out, because he was moving out of state on Saturday.

 

[HighPriest]

This was a long time ago, but my office once got a call at 4:55 pm on a Thursday from a Mom of a young adult son (never before seen by me). She stated that we had to see her son the next day and immediately take his tonsils out, because he was moving out of state on Saturday.

Man I get this kind of thing a lot.

Some of it’s military and I know that history - they’ve been trying to see a specialist for months and it took that long and now they’re on orders to PCS in a week. Sorry bro. Better luck at your next duty station.

But more often it’s this - we’re moving next Thursday can you work up and treat my sinuses before then? Also my PCP has done less than nothing. In fact they’ve somehow made it harder to work through if that’s possible.

Of course even more often I get: “it took so long to get in here that my problem went away!” And they’re angry about that. Because they need to have a problem.

 

[Pir8DeacDoc]

This was a long time ago, but my office once got a call at 4:55 pm on a Thursday from a Mom of a young adult son (never before seen by me). She stated that we had to see her son the next day and immediately take his tonsils out, because he was moving out of state on Saturday.

How'd the surgery go?
Lol

I'm truthfully amazed at patients / families on a daily basis. When you think you've seen or heard it all - you haven't.

 

[Lost in Translation]

OBGYN here. If I had a dollar for every time I got a consult for a woman of child bearing age with “vaginal bleeding” that ended up just being her period, I could afford my malpractice insurance for a year.

 

[HighPriest]

I mean, someone has to have “the talk.” Maybe you should charge for that.

 

[Apollyon]

I mean, someone has to have “the talk.” Maybe you should charge for that.

I recall almost 20 years ago, a pt I saw in the ED 3 months in a row, for "abdominal pain and vaginal bleeding". Same time, 3 months in a row. Teenager in South Carolina, with her mother. First time, I did my due diligence, but found nothing wrong, and said it was normal menses (using the colloquial "it's your period"). Then I said it again, the next month. And then I said it again, the month after that. I don't know if it finally stuck, or they just saw someone else!

 

[HighPriest]

I recall almost 20 years ago, a pt I saw in the ED 3 months in a row, for "abdominal pain and vaginal bleeding". Same time, 3 months in a row. Teenager in South Carolina, with her mother. First time, I did my due diligence, but found nothing wrong, and said it was normal menses (using the colloquial "it's your period"). Then I said it again, the next month. And then I said it again, the month after that. I don't know if it finally stuck, or they just saw someone else!

She got pregnant. Cleared right up for a while.