Post something academic, pleeeeease.

[RustedFox]

I asked nicely. I even drew out the -ee's in "please."

The thing about weird diagnoses is that we encounter them so rarely that we run the risk of not even considering them in the critical moment, or briefly considering them before discarding them. Yet, this is one of the characteristics that we pride ourselves on.

I can't remember when the last time it was that I considered methemoglobinemia, but I can answer the rest questions that they want me to answer. Poor example, maybe; but nothing else is coming to mind right now.

Maybe: "What are some less common items that we should be considering more often in our day-to-day dealings?"

 

[The Knife & Gun Club]

Cheif complaint of acute vision changes - flashes and floaters in the left eye. Ultrasound the left eye —> vitreous hemorrhage.

Weird. Get labs. Order set accidentally includes troponin. Platelets come back at 45k; trop is minimally elevated at 0.046.

Super odd. Start thinking about things. Maybe vasculitis? Send all the inflammatory crap, put them up for admission. Send a peripheral smear to path. Repeat labs with sky-high inflammatory markers, platelets now 10k.

Hematologist calls on the phone. The smear shows Schistocytes. Hematologist attending actually comes to the ED at 3am to see patient. It’s TTP. Placed a dialysis catheter, patient went to ICU for emergent plasmapheresis and steroids.

 

[bravotwozero]

I actually have that burned into my brain from my hematology lecture -

Schistocytes + thrombocytopenia = TTP

 

[The Knife & Gun Club]

I actually have that burned into my brain from my hematology lecture -

Schistocytes + thrombocytopenia = TTP

The number of times I’ve gone searching for them from the ED in my brief career has been low, and the number of time I’ve actually found them has been one.

 

[PianoMedic]

Really interesting case, never seen that yet but we get about 1-3 per year it seems through one of the hospitals I work at.

I see loads of weird stuff, not always super interesting, but I’ll start writing things down for you Rusted. I just forget usually as it all runs together for me. I’ve been told pathology has called our department extremely rarely. One doc I work with says he knows of them calling the ED 3 times in 14 years. I’ve personally spoken with them twice… But here’s a reasonably recent case, second pathologist call I’ve received, I should probably follow up on it:

Mid 40s poorly controlled diabetic comes in for abdominal pain. Started 2-3 weeks ago. Went to urgent care first, they drew labs, freaked out when they got the results and sent the patient immediately to the ED. Pain is in left upper quadrant, no other symptoms really aside from some pain also in the left shoulder. Has taken Motrin and Tylenol (which I swear no one ever even tries before they come in and are offended when I give it to them and then it works!!!), eating and drinking fine. Abdominal exam is very benign, very slight LUQ tenderness but patient also is obese so not a great exam. Hm… let’s look at those labs the midlevel didn’t know what to do wi… huh. 100k WBCs. Rest of major cell lines fine. The differential was mostly neutrophils but had various other cell types, no or few blasts, so thinking leukemoid reaction. But still, can’t really ignore that… CT scan shows either areas of infarction or developing abscesses in the spleen. Huh. Whelp, zosyn and admit. Pathologist calls nervously and states he can’t definitively rule out leukemia, so get more draws and diffs, but he is pretty sure it is leukemoid reaction. Path starts out by describing the things they’re seeing on the slide, as if I took cell bio within the past year (not almost ten years ago now) and as if I paid attention in that class (definitely not). Get to the point man!!! But it is nice being called for once and not having to page someone, although I was confused as F when they overheaded me to the desk for a call.

Patient asked if they could eat the Burger King they got on the way over to the ED when I went in to relay the CT scan results. Also was shocked that I was recommending admission to the hospital.

Still don’t know if it was a leukemia causing hyperviscosity and splenic infarction, or if it was poorly controlled diabetes leading to a splenic infection and then abscesses. I did my ID attending from med school proud and had asked earlier about travel or weird foods, which was a negative. IM took over and I know they were getting ID on board, considering gen Surg as well. Haven’t been back there for a couple weeks so I’ll update if anything interesting comes of it. Kerr sign isn’t super common but was cool to see in real life. Usually think about it with trauma, not very often in a medical type complaint.

 

[lymphocyte]

Maybe: "What are some less common items that we should be considering more often in our day-to-day dealings?"

One of my favourite trials in the last five years was the big one for status epilepticus ESETT. It compared levetiracetam, fosphenytoin, and valproate. There were no significant differences between the three but I learned one really interesting fact: a huge number of patients weren't even eligible for inclusion because they didn't get enough benzos. And the first dose wasn't adequate over 70% of the time, including in the ED setting (not just pre-hospital). It's really under-dosed by many of our colleagues. Over 32kg, I give a proper whack 10mg of midazolam or 4mg of lorazepam.

Patterns of Benzodiazepine Underdosing in the Established Status Epilepticus Treatment Trial - PMC

To describe patterns of benzodiazepine use as first-line treatment of status epilepticus (SE) and the association of benzodiazepine doses with response to second-line agents in patients enrolled in the Established Status Epilepticus Treatment Trial ...

www.ncbi.nlm.nih.gov

 

[turkeyjerky]

One of my favourite trials in the last five years was the big one for status epilepticus ESETT. It compared levetiracetam, fosphenytoin, and valproate. There were no significant differences between the three but I learned one really interesting fact: a huge number of patients weren't even eligible for inclusion because they didn't get enough benzos. And the first dose wasn't adequate over 70% of the time, including in the ED setting (not just pre-hospital). It's really under-dosed by many of our colleagues. Over 32kg, I give a proper whack 10mg of midazolam or 4mg of lorazepam.

Patterns of Benzodiazepine Underdosing in the Established Status Epilepticus Treatment Trial - PMC

To describe patterns of benzodiazepine use as first-line treatment of status epilepticus (SE) and the association of benzodiazepine doses with response to second-line agents in patients enrolled in the Established Status Epilepticus Treatment Trial ...

www.ncbi.nlm.nih.gov

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