Post acute-covid 19 syndrome

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scoopdaboop

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Thoughts, seen this at your practice? Believe the sequalae can be worse than this?

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Thoughts, seen this at your practice? Believe the sequalae can be worse than this?

Elaborate on what you think that is. PEs? Pulmonary fibrosis? "Chronic fatigue"? I need a headline syndrome?
 
Long-Covid. It’s the next line item that you’ll be adding to “24 year old female with a pmhx of anxiety, borderline, EDS, POTS, chronic Lyme....”
 
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Long-Covid. It’s the next line item that you’ll be adding to “24 year old female with a pmhx of anxiety, borderline, EDS, POTS, chronic Lyme....”

The post viral syndrome hysteria makes the headlines from time to time depending on the flu season. Most recently 2018 when it was bad. Pretty much everyone forgets it’s a thing.


Now with covid, every fearmongering media outlet has the public convinced that post covid syndrome is some new unique feature of covid that has never occurred before.

As an aside. Thrombotic risk increase with covid is also not unique; some past flu has similar risk increase https://www.ejinme.com/article/S0953-6205(15)00284-8/pdf
 
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Elaborate on what you think that is. PEs? Pulmonary fibrosis? "Chronic fatigue"? I need a headline syndrome?

Well fibrosis seems likely. But the comment above me makes it seem it's not a big deal.
 
Yes I’ve had patients with this.
Abnormal vital signs have matched up with their complaints. More tachycardic than usual, lower 02 sat. Nothing life threatening but definitely not back to baseline for a month plus.

A lot of ongoing headaches. Also, general feeling of shortness of breath, like after just walking a block or 2. I hear that more from people who used to be active exercisers/runners.

I’ve personally never seen this with the flu in younger patients under 50 like I have with Covid, but maybe patients just aren’t reporting it?

Will be interesting to see what the actual long term course will be a year+ out.
 
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Yes I’ve had patients with this.
Abnormal vital signs have matched up with their complaints. More tachycardic than usual, lower 02 sat. Nothing life threatening but definitely not back to baseline for a month plus.

A lot of ongoing headaches. Also, general feeling of shortness of breath, like after just walking a block or 2. I hear that more from people who used to be active exercisers/runners.

I’ve personally never seen this with the flu in younger patients under 50 like I have with Covid, but maybe patients just aren’t reporting it?

Will be interesting to see what the actual long term course will be a year+ out.
Yeah but how much is psychosomatic? Do they actually have measurable differences in their PFTs? VO2max? Fibrosis on CT? Bronchiectasis? Why are these people in the ER again? New process? You're going to of course see people thriving on a possible "post covid syndrome" for sympathy, attention, Instagram likes, etc. Most normal people go back to their normal lives.

I see a TON of Covid and I don't really see any sequelae overall. I see some PEs, but almost always the 2 week mark which I don't consider non acute phase. Even then it's significantly less VTE than docs/media are making it out to be. We essentially decreased the amount of CTAs we are doing significantly because they're pointless unless clinical irregularities like hypoxia without CXR changes, profound tachycardia, etc.

The exception is chronically ill LTC patients. Most of these patients are screwed up bad post covid. Almost always have multiple lab abnormalities, mental status changes, new infections, etc
 
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Yeah but how much is psychosomatic? Do they actually have measurable differences in their PFTs? VO2max? Fibrosis on CT? Bronchiectasis? Why are these people in the ER again? New process? You're going to of course see people thriving on a possible "post covid syndrome" for sympathy, attention, Instagram likes, etc. Most normal people go back to their normal lives.

I see a TON of Covid and I don't really see any sequelae overall. I see some PEs, but almost always the 2 week mark which I don't consider non acute phase. Even then it's significantly less VTE than docs/media are making it out to be. We essentially decreased the amount of CTAs we are doing significantly because they're pointless unless clinical irregularities like hypoxia without CXR changes, profound tachycardia, etc.

The exception is chronically ill LTC patients. Most of these patients are screwed up bad post covid. Almost always have multiple lab abnormalities, mental status changes, new infections, etc

Most of my patients aren’t going back to the ED, so I can’t answer that.

I’m not sure if you realize how outpatient medicine works for especially poor people, which most of my patients are we’re not getting PFTs or anything else you mention. Maybe if there are people in research studies they’re doing it?
I can only get basic like vitals signs and chest X-rays in general if a patient were to need it.

In general we’re treating symptoms, which is the general recommendation right now.

Most of my patients are going back to work and want to go back to their normal lives so no I don’t think it’s for sympathy in general. I’ve had 2 physician colleagues as well complain of lingering symptoms for about 8 weeks (since I’m not their physician not sure if they had any sort of work up like PFTs like you’re mentioning).

I obviously can’t explain the science to you, just going by what some patients are telling me and it’s not like they’re asking for narcotics or anything unreasonable, so I have no reason to not believe them. Just when I call to check on them they tell me what’s going on, so I try to provide support.

Lastly, we know things like depression and anxiety can cause physical symptoms, so even if Covid patients are more likely to have anxiety and depression and are having physical symptoms that doesn’t make it any less "real." Anxiety and depression are medical diagnoses as well that should be taken seriously.
 
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Tens of millions of people have had COVID at this point. It's unavoidable that a portion of those will have some long term effects that are real. It's equally unavoidable, that a portion of those tens of millions will blame symptoms unrelated to COVID, on their past COVID. Every generation needs it's "mitral valve prolapse," or "chronic fatigue syndrome" on which to blame all of their unrelated ills and personal deficiencies. Something was going to come along and replace "gluten" as the source of all our ills. This year it happens to be "long COVID." Next year it will be something else.
 
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Tens of millions of people have had COVID at this point. It's unavoidable that a portion of those will have some long term effects that are real. It's equally unavoidable, that a portion of those tens of millions will blame symptoms unrelated to COVID, on their past COVID. Every generation needs it's "mitral valve prolapse," or "chronic fatigue syndrome" on which to blame all of their unrelated ills and personal deficiencies. Something was going to come along and replace "gluten" as the source of all our ills. This year it happens to be "long COVID." Next year it will be something else.

Reason #6722309 why it's okay to hate the muggles.

My wife worked as a chef in a high-end restaurant. She would come home from work and report the most asinine "dietary restrictions" that the patrons reported.

Things like:

"a 30% gluten allergy" (thirty percent?)
"allergic to raw vegetables; not cooked - but raw"
"allergic to salt"

My all-time favorite was a couple who wanted to split a hamburger; but ordered each half at two different temps (medium, and well).
 
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My all-time favorite was a couple who wanted to split a hamburger; but ordered each half at two different temps (medium, and well).
The Sleep Number Burger!
 
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The Sleep Number Burger!

Basically; that's what they wanted. Could have just paid the extra cash for a second burger - but no.

More of these ridiculous requests will come to me thru the day now. Might post 'em.

Oh, wait... THIS one needs to be shared.

The kitchen has that "open" layout, where the kitchen staff can see the dining room and vice versa... Conversation overheard:

10 year old kid: "But mooom ! - I want chicken fingers, I had them last year when we were here !"
Mom: "No, honey - you have a gluten allergy this year."

"This year" ... like it was an "allergy" that could be discarded in favor of next year's en mode allergy.
 
Yes, it's a thing. Very rare though
Reason #6722309 why it's okay to hate the muggles.

My wife worked as a chef in a high-end restaurant. She would come home from work and report the most asinine "dietary restrictions" that the patrons reported.

Things like:

"a 30% gluten allergy"
"allergic to raw vegetables; not cooked - but raw"
"allergic to salt"

My all-time favorite was a couple who wanted to split a hamburger; but ordered each half at two different temps (medium, and well).
My brother in law is a chef. He says "people who claim an onion allergy...just don't like good food."
 
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I saw my first post-COVID GBS case last night. Strange presentation with lumbar back pain (not that rare in GBS) and proximal > distal leg weakness (turns out after reading some case series, while not classic, also apparently not that rare) with weakness at hip flexors but not as impressive at knees/ankles on exam. Brief mention of some tingling to hands but normal strength there. It really looked like a "can walk but won't walk due to pain and poor copings skills" sort of picture at first. With some grumbling from hospitalist, pt got admitted for can't walk + PT/MRI in AM, found to have COVID on admission screen (no respiratory symptoms or fever, mentioned a mild URI ~ weeks ago) and had elevated inflammatory markers so got tapped and was found to have elevated protein. It's everywhere, watch out and wear your PPE!
 
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I saw my first post-COVID GBS case last night. Strange presentation with lumbar back pain (not that rare in GBS) and proximal > distal leg weakness (turns out after reading some case series, while not classic, also apparently not that rare) with weakness at hip flexors but not as impressive at knees/ankles on exam. Brief mention of some tingling to hands but normal strength there. It really looked like a "can walk but won't walk due to pain and poor copings skills" sort of picture at first. With some grumbling from hospitalist, pt got admitted for can't walk + PT/MRI in AM, found to have COVID on admission screen (no respiratory symptoms or fever, mentioned a mild URI ~ weeks ago) and had elevated inflammatory markers so got tapped and was found to have elevated protein. It's everywhere, watch out and wear your PPE!
That's a good case and the kind that's easy for some to miss.
 
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Reason #6722309 why it's okay to hate the muggles.

My wife worked as a chef in a high-end restaurant. She would come home from work and report the most asinine "dietary restrictions" that the patrons reported.

Things like:

"a 30% gluten allergy"
"allergic to raw vegetables; not cooked - but raw"
"allergic to salt"

My all-time favorite was a couple who wanted to split a hamburger; but ordered each half at two different temps (medium, and well).
So, disappointingly, this one actually might be real - oral allergy syndrome. IgE mediated reaction to a highly conserved protein that denatures with heat. But 100% to the rest of the EDS etc.
 
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Med student here. I personally had a post-viral syndrome that sounds similar to some of what's being described with covid, but mine was after mono. Joint/bone pain, cognitive problems, fatigue, paresthesias in my extremities, and some dysautonomia (though I wasn't a medical person at the time so I didn't know what to call it).

I can say that it was very real (not psychosomatic, thank you very much), it lasted about a year, & I never got back 100% to baseline - just found a new normal. I did not at all benefit from having it, and given that I was in my early 20's at the time and seemingly healthy prior, it felt like it came out of nowhere. I was absolutely terrified that I wouldn't recover and would be functionally disabled. My doctors were all well intentioned (and I saw several), but they had no idea what to tell me other than, "Rest when your body tells you to and try PT. Hopefully it will get better, but we can't promise you anything. Your immune system may be damaged (positive ANA), but we can't find anything else in particular to guide your treatment."

There's still a lot we don't understand about covid, and frankly a lot we still don't know about how the body works. And we'll never learn those those things if we look at patients who have symptoms we can't explain and conclude they must be faking, exaggerating, or that it's really just a psychiatric problem. It does real harm when we choose to ignore part of the data set because it doesn't fit our hypothesis - not to mention the damage it does to individual patients.
 
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Med student here. I personally had a post-viral syndrome that sounds similar to some of what's being described with covid, but mine was after mono. Joint/bone pain, cognitive problems, fatigue, paresthesias in my extremities, and some dysautonomia (though I wasn't a medical person at the time so I didn't know what to call it).

I can say that it was very real (not psychosomatic, thank you very much), it lasted about a year, & I never got back 100% to baseline - just found a new normal. I did not at all benefit from having it, and given that I was in my early 20's at the time and seemingly healthy prior, it felt like it came out of nowhere. I was absolutely terrified that I wouldn't recover and would be functionally disabled. My doctors were all well intentioned (and I saw several), but they had no idea what to tell me other than, "Rest when your body tells you to and try PT. Hopefully it will get better, but we can't promise you anything. Your immune system may be damaged (positive ANA), but we can't find anything else in particular to guide your treatment."

There's still a lot we don't understand about covid, and frankly a lot we still don't know about how the body works. And we'll never learn those those things if we look at patients who have symptoms we can't explain and conclude they must be faking, exaggerating, or that it's really just a psychiatric problem. It does real harm when we choose to ignore part of the data set because it doesn't fit our hypothesis - not to mention the damage it does to individual patients.

There's so many red flags here I don't know where to start. Not even surprised you've seen "multiple different physicians"
 
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N=1 but I can confirm there’s atleast some of us who have persistent symptoms. I had it and ever since my exercise tolerance has been way down because I get short of breath 5 months afterwards. Young healthy guy.

Can’t get objective data like CTs of my lungs or PFTs cause I moved out of the state that my Medicaid is registered in and it’s really not bad enough for me to bother if I had the resources but it’s definitely noticeable.

Definitely not something that I’d resort to the ED for either.
 
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There's so many red flags here I don't know where to start. Not even surprised you've seen "multiple different physicians"

Awww, I know, right?! Seeing multiple physicians because the pcp sent me to specialists because she didn't know & wanted to help me is definitely a big old red flag. Totally invalidates anything I could possibly contribute to this conversation. /s

You're going to keep being invalidating & dismissive of me (& anyone else with experiences that don't align with your own). You'll keep hurting your patients by telling them their pain & symptoms aren't real. & there's nothing I can do to change that. Wish could, but I can't. I shared my perspective in the hope of doing some good, but clearly it's not welcome here.
 
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90% of heart transplants are due to viral myocardities, usually Coxsackie virus. I would NOT be surprised if the COVID leads to something similar. People here have written about EF decreases after the COVID resolved.

As someone wrote in another forum here on SDN, maybe invest in companies that make LVADs!
 
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I saw my first post-COVID GBS case last night. Strange presentation with lumbar back pain (not that rare in GBS) and proximal > distal leg weakness (turns out after reading some case series, while not classic, also apparently not that rare) with weakness at hip flexors but not as impressive at knees/ankles on exam. Brief mention of some tingling to hands but normal strength there. It really looked like a "can walk but won't walk due to pain and poor copings skills" sort of picture at first. With some grumbling from hospitalist, pt got admitted for can't walk + PT/MRI in AM, found to have COVID on admission screen (no respiratory symptoms or fever, mentioned a mild URI ~ weeks ago) and had elevated inflammatory markers so got tapped and was found to have elevated protein. It's everywhere, watch out and wear your PPE!
You were able to admit that without tapping first?
 
Emergent LP is not indicated for that patient. It’s part of the work up that can be done upstairs.
Indicated vs required for admission are different.

That said if you’re considering GBS don’t you think that warrants a tap as it would change manangement?
 
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Indicated vs required for admission are different.

That said if you’re considering GBS don’t you think that warrants a tap as it would change manangement?

Also an incredibly vague presentation. Extreme stretch for GBS imo. No way that gets admitted at my shop, especially right now. You'd need a positive LP for sure. I'd also argue that it would be an "emergent" LP if you're looking for GBS. Guessing a lot more to the story.
 
Also an incredibly vague presentation. Extreme stretch for GBS imo. No way that gets admitted at my shop, especially right now. You'd need a positive LP for sure. I'd also argue that it would be an "emergent" LP if you're looking for GBS. Guessing a lot more to the story.

Nonspecific weakness in a young person? Slam dunk admission for neurology consult/MRI in the morning. No need for emergent LP unless fever or other signs of meningitis.
 
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Nonspecific weakness in a young person? Slam dunk admission for neurology consult/MRI in the morning. No need for emergent LP unless fever or other signs of meningitis.
I’m not saying this logic is wrong. Just doesn’t seem commonplace.
“Why can’t they see Neuro in the clinic this week?”
“They’re weak? What if they have GBS?”
“Well do they?”
...
 
I’m not saying this logic is wrong. Just doesn’t seem commonplace.
“Why can’t they see Neuro in the clinic this week?”
“They’re weak? What if they have GBS?”
“Well do they?”
...

Don't be sucked into the mantra that everyone getting admitted to the hospital needs a definitive diagnosis. If you're being wishy-washy and meek with your story and reasoning for admission to the hospital then you're going to get pushback.
 
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Don't be sucked into the mantra that everyone getting admitted to the hospital needs a definitive diagnosis. If you're being wishy-washy and meek with your story and reasoning for admission to the hospital then you're going to get pushback.
Look fellas. I’ve dealt with dick head academic hospitalist blocking reasonable admissions many a time. In this case I would say an admitting doctor asking for a more specific reason for admission (like what are they going to work up/rule out) or CSF to establish a diagnosis of GBS (which maybe isn’t emergent but usually requires in patient treatment, hence the tap) isn’t unreasonable.
 
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Look fellas. I’ve dealt with dick head academic hospitalist blocking reasonable admissions many a time. In this case I would say an admitting doctor asking for a more specific reason for admission (like what are they going to work up/rule out) or CSF to establish a diagnosis of GBS (which maybe isn’t emergent but usually requires in patient treatment, hence the tap) isn’t unreasonable.

It's more unreasonable than asking someone to do a non-emergent LP in the ED. Patient needs a Neurology consult with LP done by Neuro/IR. Admit. On to the next patient. The good news is that they can get their inpatient treatment once the results are back from their inpatient LP.
 
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It's more unreasonable than asking someone to do a non-emergent LP in the ED. Patient needs a Neurology consult with LP done by Neuro/IR. Admit. On to the next patient. The good news is that they can get their inpatient treatment once the results are back from their inpatient LP.
They need an emergent/inpatient Neuro consult? Can they see Neuro in the clinic?
 
90% of heart transplants are due to viral myocardities, usually Coxsackie virus. I would NOT be surprised if the COVID leads to something similar. People here have written about EF decreases after the COVID resolved.

As someone wrote in another forum here on SDN, maybe invest in companies that make LVADs!
That's a good financial tip. The covid-heart connection is pretty underrated unfortunately
 
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The larger the laceration, the larger the scar. I suspect it also holds true that a more severe infection leads to greater myocardial or pulmonary scarring in the form of fibrosis. I doubt most with mild to moderate non-hospitalized infections are going to have significant fibrosis with subsequent reduction in LVEF or PFTs, while those hospitalized or critically ill will end up with worse scars. Most aren’t going to need a transplant or an LVAD. Maybe worth investing though in new medical technology given society’s goals of care.

What about HFpEF?

 
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They need an emergent/inpatient Neuro consult? Can they see Neuro in the clinic?

Not unless Neuro can see them tomorrow (they can't) and they will do an LP in their clinic (they won't). Easy admit.
 
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Indicated vs required for admission are different.

That said if you’re considering GBS don’t you think that warrants a tap as it would change manangement?

I don't actually think GBS is an emergency. It's kind of like COVID - from onset of symptoms to peak physiologic debilitation takes a few weeks. There is really nothing emergent about it unless the patient presents paralyzed and unable to breathe. But you would be thinking of other things at that time anyway and not GBS.

Even though I don't think it's an emergency, it's something that generally should be admitted.
 
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I don't actually think GBS is an emergency. It's kind of like COVID - from onset of symptoms to peak physiologic debilitation takes a few weeks. There is really nothing emergent about it unless the patient presents paralyzed and unable to breathe. But you would be thinking of other things at that time anyway and not GBS.

Even though I don't think it's an emergency, it's something that generally should be admitted.
GBS is definitely an emergency....The issue is many times you don’t actually know the true time of onset. When patients finally come in to complain of “few days of weakness” it typically has been a few weeks already of subtle progressive changes (like mild sensory changes, back discomfort) that they may not endorse or notice and impending respiratory failure can arise

It’s not like they sit around at home checking deep tendon reflexes daily
 
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You were able to admit that without tapping first?

Others have covered this, but essentially it was a vague presentation that was not classic and to be honest I did not think of GBS until the COVID test was positive and inflammatory markers were up. We didn't have night-time MRI access and the patient was stable (and like I said, their exam was proximal weakness in the lower extremities, essentially normal distal to the hips) so we initially planned on an admission for MRI/PT/Pain control and possibly neuro consult if symptoms didn't improve with pain control. When the tests pointed towards possible COVID weirdness, the differential was expanded and the diagnosis was made. A learning point for me is that, in one case series at least, a large portion of AIDP/GBS patients will have proximal > distal weakness in the legs.

But to your point and to others, yes, I (rarely) admit patients with intractable pain who can't walk and would not transfer for MRI if they have an exam that suggests against cauda equina or acute cord compression needing emergent decompression. We have great hospitalists.
 
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I'm glad you guys are able to admit this. I have no problem with this admission from a patient centered standpoint. Just in my experience this would be a tough sell without CSF (unless they can't walk, that changes things).
 
Nonspecific weakness in a young person? Slam dunk admission for neurology consult/MRI in the morning. No need for emergent LP unless fever or other signs of meningitis.

If we're talking about true physical exam weakness here then admitting for "MRI in the morning" is inappropriate. I'd argue you need an emergent MRI for neurosurgical intervention. If you have hard neurologic signs then you're at the point of "time is brain" or neuropathways in this case. Other spinal cord pathologies exist beyond cauda equina (which presents classically less than 50% of the time). If negative then do the LP since this isn't classic GBS presentation. Then admit.

Most "admission MRIs" get de prioritized to nonstat. He might get it two days from now. Now he can't walk. Pretty much a slam dunk malpractice case for nsg to throw EM under the bus.
 
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If we're talking about true physical exam weakness here then admitting for "MRI in the morning" is inappropriate. I'd argue you need an emergent MRI for neurosurgical intervention. If you have hard neurologic signs then you're at the point of "time is brain" or neuropathways in this case. Other spinal cord pathologies exist beyond cauda equina (which presents classically less than 50% of the time). If negative then do the LP since this isn't classic GBS presentation. Then admit.

Most "admission MRIs" get de prioritized to nonstat. He might get it two days from now. Now he can't walk. Pretty much a slam dunk malpractice case for nsg to throw EM under the bus.

I agree that if there was some combo of back pain and weakness I am probably transferring to a place that has nsgry and emergent mri.

If I don’t suspect meningitis or sah/iph I’m probably not doing the tap, especially since anything beyond a gram stain/culture is a send out for our lab for reasons I don’t understand.

I don’t think there’s much of an argument for a tap in this patient in the ed. GB is a clinics dx, not a lab dx.

Internists are also credentialed to do lps (lol not gonna happen) and they have multiple consulting services that can do them as well (what will happen, usually rads or ir).

While the mri downgrade is a thing, if you order it emergently and after admit someone downgraded it that’s on them and the admitting team. I am not following the pt to the floor or wherever they are transferred to ensure they aren’t doing stupid stuff.

And I don’t need a diagnosis to tell someone this patient needs admission. It’s a young person that can’t walk due to objective proximal weakness with progression of disease. That 100% mandates an admission in my book, and there’s no amount of pushback someone could give me that would convince me otherwise.

If the hospitalist would actually say that this can follow in clinic then they’re an idiot. I would also escalate past them or transfer the patient (both of which would raise hell from an admin standpoint) if they refused this patient, but I would likely have already consulted the other services to arm myself here anyway (hi dr neurosurg, I’m admitting this to hospitalist k thx bye).

As an aside I don’t ever say “what if it’s blank” I say “ I think it’s blank. They have x y z. They have to come in for a b c.” If they say “why not outpt” we circle back to “ I think it’s blank. They need a b c.” This cycle continues until they either admit or see the patient (98% are admits, and usually they’re chicken shi* when they actually see em).
 
GBS is definitely an emergency....The issue is many times you don’t actually know the true time of onset. When patients finally come in to complain of “few days of weakness” it typically has been a few weeks already of subtle progressive changes (like mild sensory changes, back discomfort) that they may not endorse or notice and impending respiratory failure can arise

It’s not like they sit around at home checking deep tendon reflexes daily

It’s also a clinical diagnosis. Many of these patients have negative lps the first week or two, and a solid 10% have ongoing negative lps through week two.

This one isn’t a slam dunk, so the lp is helpful, but again not necessary in ed. If they have a failing negative inspiratory force/vital capacity or distress, intubate and icu for plasmapheresis/ivig.

This is one where if I have time I get csf but if not I admit it anyway.
 
Bizarre single-person anecdotes, wild conclusions from tiny, non-controlled studies, and media hype of "experts" with financial conflict. Long COVID has it all!

I have to go now, and tend to my status lymphaticus.
 
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Internists are also credentialed to do lps (lol not gonna happen) and they have multiple consulting services that can do them as well (what will happen, usually rads or ir).
Not where I trained...I looked at the procedural requirements in the Internal Medicine RRC and it didn't have LP. Internal medicine's procedural requirements are becoming fewer and fewer as decades go by
 
Not where I trained...I looked at the procedural requirements in the Internal Medicine RRC and it didn't have LP. Internal medicine's procedural requirements are becoming fewer and fewer as decades go by

I've never seen any internist do a procedure. They cant/won't do even a simple lac repair or place a rhino rocket on a floor patient. They call me all the time for this BS and I politely refuse.
 
I've never seen any internist do a procedure. They cant/won't do even a simple lac repair or place a rhino rocket on a floor patient. They call me all the time for this BS and I politely refuse.

Yup they don't do s^it. I'm not even sure they touch patients during a physical exam.
 
Yup they don't do s^it. I'm not even sure they touch patients during a physical exam.
I saw an internist do a procedure once. He popped a zit on himself in the hospital bathroom after the Derm 2nd year refused to do it.
 
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Not where I trained...I looked at the procedural requirements in the Internal Medicine RRC and it didn't have LP. Internal medicine's procedural requirements are becoming fewer and fewer as decades go by

Huh. Ours have it on their list but I’ve never heard of it happening. Where I did residency they could (but would not).
 
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