I hate ending up in M&M

[The White Coat Investor]

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[EctopicFetus]

even if you end up in M&M it doesnt mean you did anything wrong... sound reasonable IMO.. sux for her.

 

[edinOH]

Each day I do this job I realize more and more how, despite how hard you try to do the right thing for patients based on your best judgment and reasoning, we are still figuratively dodging bullets with each patient we see. It will drive you crazy if you dwell on it.

 

[mikecwru]

I saw a patient...typical fibromyalgia depressed middle aged female, pain started while pushing a stroller at a theme park 2 months prior. Had had 5 primary care visits over the last 2 months for her back pain. Had an MRI scheduled in 10 days or so. Was seen by my partner the day before and put on dilaudid and also was complaining of constipation, which I attributed naturally to the dilaudid and the other narcotics she had been on. No red flags. No fevers, no vomiting, no abdominal pain, no weakness, no numbness, no incontinence, normal neuro exam. I narced her up, she felt a bit better, and I discharged her. She came back about an hour later (never really made it out of the parking lot according to her husband) and I figured 3 visits in 24 hours time to admit her, expedite the MRI, and get her a pain control plan. She got scanned later that night and had a B-cell lymphoma pressing on her spinal cord. Oooh...I hate that.

There are many people who wouldn't have even admitted her. I can't think of a lot of people who would have jumped and MRI'd her on your ED visit. I wouldn't consider constipation a red flag.

mike

 

[deleted109597]

There are many people who wouldn't have even admitted her. I can't think of a lot of people who would have jumped and MRI'd her on your ED visit. I wouldn't consider constipation a red flag.

mike

Exactly. However, if she had decreased sphincter tone, maybe then. But that's about it.

 

[kungfufishing]

oh, no this is obviously a case of B Cell lymphoma with spinal cord compression.

Kidding. that sucks and is scary.

 

[USCDiver]

I've had a similar case... although I wouldn't consider either M&M.

Elderly lady, 77yo or something, had a visit to the ED approx 2 weeks prior for back pain, improved with PO narcs or something. Came back with weakness, falls, and continued back pain. Fellow resident CT'd her LS spine which was negative. Home on narcs. Came back in a few days later, it was a Monday morning (I remember because our former Chair, now Assistant Dean was working and he only works Monday mornings). Anyway, she was unable to walk now 'because of the pain' but she really was weak. MRI'd her that morning. She had a bunch of leptomeningeal tumors in her distal cord and cauda. Blech... at least we got a diagnosis.

 

[southerndoc]

M&M is ok. It's the D&D meetings that aren't fun. D&D is death and donuts. At least the donuts keep your tummy satisfied while your nerves are on edge.

 

[EctopicFetus]

So I saw them wheel this guy back to CT today.. I saw him a few days ago and he was seen prior to that as well. His complaint is R cheek pain. No trauma, possible sinusitis (which I treated). What might I be missing? I will have to follow up on what his story is when I get back to work.. A possible M&M?

 

[DropkickMurphy]

So I saw them wheel this guy back to CT today.. I saw him a few days ago and he was seen prior to that as well. His complaint is R cheek pain. No trauma, possible sinusitis (which I treated). What might I be missing? I will have to follow up on what his story is when I get back to work.. A possible M&M?

It's obviously one of those brain parasites you get from eating raccoon feces. Didn't you know they go through their second stage of life in the maxillary sinuses before migrating to the brain? Just kidding....I have no idea.

 

[Orthonut]

It's obviously one of those brain parasites you get from eating raccoon feces. Didn't you know they go through their second stage of life in the maxillary sinuses before migrating to the brain? Just kidding....I have no idea.

um, hate to break it to ya Murph, but there actually are parasites that do something similar (they sometimes end up in the brain of certain patient species-but AFAIK, usually just cat and rabbit brain, never humans)

Warbles are the larval stage of the botfly, which characteristically infect rodents and rabbits. They are found under the skin, usually around the legs and neck. They have also been reported from deer, cattle, cats, dogs, hogs, mules, mink, foxes and man....The larvae enter the host by way of a natural body opening, commonly the nose or mouth, or a minute abrasion of the skin. They frequently remain in oral and nasal passages several days before migrating to preferred locations under the skin, where they develop into warbles.

http://www.michigan.gov/dnr/0,1607,7-153-10370_12150_12220-26354--,00.html

kinda gross, eh? I was going to put a picture in but that's just...mean.

 

[The White Coat Investor]

So I saw them wheel this guy back to CT today.. I saw him a few days ago and he was seen prior to that as well. His complaint is R cheek pain. No trauma, possible sinusitis (which I treated). What might I be missing? I will have to follow up on what his story is when I get back to work.. A possible M&M?

Fungal sinusitis...osteomyelitis...meningitis...orbital cellulitis....his cold still isn't better....who knows

 

[bartleby]

Aortic dissection, obviously. Well-known atypical presentation (described in a case series of two patients, JAMA, 1967)

So I saw them wheel this guy back to CT today.. I saw him a few days ago and he was seen prior to that as well.

 

[kbrown]

I saw a patient...typical fibromyalgia depressed middle aged female, pain started while pushing a stroller at a theme park 2 months prior. Had had 5 primary care visits over the last 2 months for her back pain. Had an MRI scheduled in 10 days or so. Was seen by my partner the day before and put on dilaudid and also was complaining of constipation, which I attributed naturally to the dilaudid and the other narcotics she had been on. No red flags. No fevers, no vomiting, no abdominal pain, no weakness, no numbness, no incontinence, normal neuro exam. I narced her up, she felt a bit better, and I discharged her. She came back about an hour later (never really made it out of the parking lot according to her husband) and I figured 3 visits in 24 hours time to admit her, expedite the MRI, and get her a pain control plan. She got scanned later that night and had a B-cell lymphoma pressing on her spinal cord. Oooh...I hate that.

I actually had this exact same patient only female. We had the exact same problem with him, multiple visits, pain control, blah...came back the morning after I discharged him b/c of a fall. Admitted. MRI with B cell spinal compression. Unfortunately for him, after three weeks in the hospital he was made comfort care and passed away.

 

[DropkickMurphy]

um, hate to break it to ya Murph, but there actually are parasites that do something similar (they sometimes end up in the brain of certain patient species-but AFAIK, usually just cat and rabbit brain, never humans)


http://www.michigan.gov/dnr/0,1607,7-153-10370_12150_12220-26354--,00.html

kinda gross, eh? I was going to put a picture in but that's just...mean.

I wasn't being sarcastic when I posted what I said.....I knew it actually happened.

 

[DropkickMurphy]

Fungal sinusitis...osteomyelitis...meningitis...orbital cellulitis....his cold still isn't better....who knows

I now have Monty Python's "Medical Love Song" running through my head because of this post......

 

[deleted77919]

I wasn't being sarcastic when I posted what I said.....I knew it actually happened.

There are human brain worms (cystercercus). In fact there was an epidemic in Brooklyn some years ago among Hasidic Jews from Taenia solium, pork tape worms. Somehwat embarassing. Turns out they had a cook from lating america who was infected then got the eggs into the food, if humans ingest the eggs then the larval stage often migrates to the brain.

 

[Orthonut]

There are human brain worms. I swore I saw something like this on the discovery channel, and I'm certain this is what they were talking about (yeah, yeah, not the best of sources, but enough for me to confirm my discovery channel vague memory).

http://pr.caltech.edu/periodicals/eands/articles/LXVI4/brainworms.html

Brainworms. You guys have cooler names for them than we do. We call them "cuterebra" lol. A friend had a client bring one in on emergency-they had "rescued" it from it's cruel mother mouse-who abandoned it. She was like "um, hate to break it to you but...that's not no baby mouse you gave mouth to mouth to..."

 

[beyond all hope]

I've already had 2 M&Ms about me in my first 6 months as an attending. One was a cool rare case that got written up that everyone agrees I did nothing wrong. The other was a MI that I spent an extra 2 hours dicking around to get a CT vs dissection. Pt did fine, Cards was pissed b/c he waited a while to go to the cath lab, which is understandable. Probably should have called cards for the STEs while I was getting the CT.

No actual badness yet. Just a matter of time.

 

[Annette]

They are just a way to remind us that even end-stage, metastatic, terminal fibromyalgia (ESMTF) patients have real pathology now and again. Yeah, it sucks to have gotten the case, but you've done the right things. EM was meant to rule out the immediate nasties, not the long term ones.

 

[dchristismi]

There are human brain worms. I swore I saw something like this on the discovery channel, and I'm certain this is what they were talking about (yeah, yeah, not the best of sources, but enough for me to confirm my discovery channel vague memory).

http://pr.caltech.edu/periodicals/eands/articles/LXVI4/brainworms.html

Not to derail this thread any more, but we see a ton of cystercercosis. Really. I didn't figure it would be such a prominent thing, but it certainly is here.