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I don't irrigate cerumen impaction. Especially not on a busy shift like this. I tell them to pick up some debrox and they get ENT referral if they want to follow up. Not an ER issue.
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I don't irrigate cerumen impaction. Especially not on a busy shift like this. I tell them to pick up some debrox and they get ENT referral if they want to follow up. Not an ER issue.
Polite request to finish the box score for the shift, here.
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I have the tech irrigate then then pop in and get out what little is left with a curette. Easy 0.61 rvus.
FYI: if you don't curette it, it's 0 rvus. If you don't have a tech, they can GTFO.
Yes, I know how mercenary this is. If you're coming into the ED for obvious b***s*** I'm going to make it worth my while, or I'm not going to bother at all.
So, for some reason I thought that you could bill for either the E/M code, or the cerumen removal, but not both. Or is it that you can bill for both, but only if you use a curette?
Not gonna lie, I always hope that the vertigo they get from irrigation will dissuade them from coming back.
Updated above.
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Requirements for reporting impacted cerumen removal with an E/M on the same DOS
When reporting an E/M visit AND cerumen removal on the same date of service, the following criteria must be met:
• The main reason for the patient’s visit was separate from the cerumen removal
• Otoscopic examination of the tympanic membrane is not possible due to the impaction
• Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner
• The procedure requires a significant amount of time and effort, and all of the above criteria are clearly
documented in the patient’s medical record
The only hard part is the first one. You need to be able to document a visit for something other than "ears plugged." Otitis media works. Dizziness works. Headache works.
As for your vertigo hopes... sometimes tap water is really cold and you don't realize that it hasn't warmed up yet when you're filling the spray bottle. Just saying.
10 hr shift:
1. 56 yo F assaulted on face yesterday by a friend's cane. Didn't need imaging. d/c
2. 65 yo M with renal transplant, DM, with cellulitis on hand and wrist after cutting himself. Rx keflex/doxy. d/c
3. 81 yo F who is homeless, 15th visit this year, p/w weakness. Just seen 2 days ago for same thing. Nothing done on this visit. d/c
4. 24 yo F 21 wks pregnant had a failed PICC for TPN due to hyperemesis. Also has catheter induced blood clot. Admit to L&D for another PICC.
5. 69 yo F had outpatient renal US and showed possible aortic dissection flap. Rads sent in for angio. Angio neg. d/c
6. 75 yo F has LH and nausea. Just hospitalized a few days ago for mild type 2 MI. Eveyrthing is normal but didn't want to go home until she was "back to normal." Took several hours of nonsense interventions but she got better. "I'm getting better! I'm not dead yet!" d/c
7. 75 yo F with symptomatic afib 110-130. She feels palpitations. Marked dyspnea on exertion. Labs, CXR, dilt x2, metop, and admit.
8. 60 yo F with chronic pancytopenia (from MDS) has b/l leg cellulitis. Labs OK. admit
9. 64 yo F with trach from anaplastic thyroid cancer has cellulitis around her trach. Standard labs, abx, and admit.
10. 27 yo M with DM has FSG 700, colitis and ascites. Weird combo. admit.
11. 21 yo F fainted while starting a job today. EKG normal. vasovagal syncope. d/c
12. (signout) 80 yo F with left facial droop. Likely bells and asked to f/u MRI. MRI neg. d/c
13. 74 yo M with foley problems, possibly leakage. Nurse twiddled the foley. Bladder empty on US. d/c
14. 70 yo F p/w leg cellulitis, just discharged 3 days ago for same thing. Home health nurse sent her in to be "evaluated". Eval performed and no medical emergency. f/u PCP/podiatry. d/c
15. (signout) 9 yo F with asthma and hypoxic 84%. Required a lot of treatment but eventually got much better. She never appeared sick. d/c O2 was 93-94%. Spend about 10 hrs total in ED. d/c
16. 75 yo M with CP. No CP in ED, EKG and two trops neg. HEART 3? maybe 4? I don't really remember. d/c for PCP workup.
17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago."
d/c
18. 25 yo F with brief RUQ pain. Feeling better. Probably her fatty liver causing her problem. d/c
19. 74 yo M, regularly drunk, brought in on 5150 because he shoved his wife and made bad comments about her. He is drunk today. Wow how about that. asked SS to take care of this case. presumably discharged on a subsequent shift.
20. 16 yo F hurt BOTH ankles playing volleyball. Both are not broken. She was able to hop out of the ED on her better ankle. I gave her a high-five in front of her parents and said "you are going places my dear! You are a keeper!" She smiled and was obviously very happy with the outcome. d/c
21. 48 yo F sent in by PCP for Hg 5. She gets post-coital bleeding and prior notes suggests she has a cervical mass. I said "Please no more sex until you get this fixed" and she smiled. She wasn't bleeding in the ED. after pRBC and IV iron sucrose, d/c
22. 13 yo F with no BM for 5 days. Rx 4 different medicines to make her to poop! d/c
23. 15 yo F with traumatic foot pain, has broken 5th metatarsal. d/c
24. 30 yo M with post-surgical wrist pain. exam benign, XR stable. d/c
25. 38 yo M with LBP and scrotal pain. Exam, UA, and scrotal US are OK. He was very comfortable. d/c
26. 43 yo F with traumatic pinky toe pain. It's broke. d/c
27. 42 yo F has broken qtip in her ear. I pulled it out. d/c
Wish I could go back in time to 1980 and see what a day in the life was like for ER docs.
1. 56 yo F assaulted on face yesterday by a friend's cane. Didn't need imaging. d/c
2. 65 yo M with renal transplant, DM, with cellulitis on hand and wrist after cutting himself. Rx keflex/doxy. d/c
3. 81 yo F who is homeless, 15th visit this year, p/w weakness. Just seen 2 days ago for same thing. Nothing done on this visit. d/c
4. 24 yo F 21 wks pregnant had a failed PICC for TPN due to hyperemesis. Also has catheter induced blood clot. Admit to L&D for another PICC.
5. 69 yo F had outpatient renal US and showed possible aortic dissection flap. Rads sent in for angio. Angio neg. d/c
6. 75 yo F has LH and nausea. Just hospitalized a few days ago for mild type 2 MI. Eveyrthing is normal but didn't want to go home until she was "back to normal." Took several hours of nonsense interventions but she got better. "I'm getting better! I'm not dead yet!" d/c
7. 75 yo F with symptomatic afib 110-130. She feels palpitations. Marked dyspnea on exertion. Labs, CXR, dilt x2, metop, and admit.
8. 60 yo F with chronic pancytopenia (from MDS) has b/l leg cellulitis. Labs OK. admit
9. 64 yo F with trach from anaplastic thyroid cancer has cellulitis around her trach. Standard labs, abx, and admit.
10. 27 yo M with DM has FSG 700, colitis and ascites. Weird combo. admit.
11. 21 yo F fainted while starting a job today. EKG normal. vasovagal syncope. d/c
12. (signout) 80 yo F with left facial droop. Likely bells and asked to f/u MRI. MRI neg. d/c
13. 74 yo M with foley problems, possibly leakage. Nurse twiddled the foley. Bladder empty on US. d/c
14. 70 yo F p/w leg cellulitis, just discharged 3 days ago for same thing. Home health nurse sent her in to be "evaluated". Eval performed and no medical emergency. f/u PCP/podiatry. d/c
15. (signout) 9 yo F with asthma and hypoxic 84%. Required a lot of treatment but eventually got much better. She never appeared sick. d/c O2 was 93-94%. Spend about 10 hrs total in ED. d/c
16. 75 yo M with CP. No CP in ED, EKG and two trops neg. HEART 3? maybe 4? I don't really remember. d/c for PCP workup.
17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago."
d/c18. 25 yo F with brief RUQ pain. Feeling better. Probably her fatty liver causing her problem. d/c
19. 74 yo M, regularly drunk, brought in on 5150 because he shoved his wife and made bad comments about her. He is drunk today. Wow how about that. asked SS to take care of this case. presumably discharged on a subsequent shift.
20. 16 yo F hurt BOTH ankles playing volleyball. Both are not broken. She was able to hop out of the ED on her better ankle. I gave her a high-five in front of her parents and said "you are going places my dear! You are a keeper!" She smiled and was obviously very happy with the outcome. d/c
21. 48 yo F sent in by PCP for Hg 5. She gets post-coital bleeding and prior notes suggests she has a cervical mass. I said "Please no more sex until you get this fixed" and she smiled. She wasn't bleeding in the ED. after pRBC and IV iron sucrose, d/c
22. 13 yo F with no BM for 5 days. Rx 4 different medicines to make her to poop! d/c
23. 15 yo F with traumatic foot pain, has broken 5th metatarsal. d/c
24. 30 yo M with post-surgical wrist pain. exam benign, XR stable. d/c
25. 38 yo M with LBP and scrotal pain. Exam, UA, and scrotal US are OK. He was very comfortable. d/c
26. 43 yo F with traumatic pinky toe pain. It's broke. d/c
27. 42 yo F has broken qtip in her ear. I pulled it out. d/c
Wish I could go back in time to 1980 and see what a day in the life was like for ER docs.
Can't just get a "change of scenery" as you suggest, and have it at least pan out the way you want it to.
Admitted 5 I think...and had like 3 CC time. This was an average shift, maybe below average for acuity. I tend to admit less than my partners. For instance that 75 M with CP...I think more than 1/2 of all ER docs would just admit that guy although I saw no point in doing that.
Most of the posts / shifts from others have nonsense stuff.
Admitted 5 I think...and had like 3 CC time. This was an average shift, maybe below average for acuity. I tend to admit less than my partners. For instance that 75 M with CP...I think more than 1/2 of all ER docs would just admit that guy although I saw no point in doing that.
Most of the posts / shifts from others have nonsense stuff.
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Next time I have a good shift I'll post it. Occasionally I get some. My impression is that all of us seem to have a nonsense % factor somewhere in the 50-75% range. One dude a while ago posted a shift where he admitted like 10-12 people, many to the ICU.
I had one crispy day a week ago. My last shift was fine. I'm fine 98% of the time.
We all work like 14-16 shifts somewhere in that range. I reckon 75% of those shifts are neutral, you go to work and you leave work and nothing else to it. Of the remaining 25%...the majority of those should be good. Maybe you have 1-2 hard shifts / month. It's like all work, whether you are plumber, statistician, horse manure cleaner-upper, middle salesman for an auto-parts store, IP lawyer, or an elite escort in St. Louis.
I had one crispy day a week ago. My last shift was fine. I'm fine 98% of the time.
We all work like 14-16 shifts somewhere in that range. I reckon 75% of those shifts are neutral, you go to work and you leave work and nothing else to it. Of the remaining 25%...the majority of those should be good. Maybe you have 1-2 hard shifts / month. It's like all work, whether you are plumber, statistician, horse manure cleaner-upper, middle salesman for an auto-parts store, IP lawyer, or an elite escort in St. Louis.
I like your style. Keep it up. Very productive and lean.10 hr shift:
1. 56 yo F assaulted on face yesterday by a friend's cane. Didn't need imaging. d/c
2. 65 yo M with renal transplant, DM, with cellulitis on hand and wrist after cutting himself. Rx keflex/doxy. d/c
3. 81 yo F who is homeless, 15th visit this year, p/w weakness. Just seen 2 days ago for same thing. Nothing done on this visit. d/c
4. 24 yo F 21 wks pregnant had a failed PICC for TPN due to hyperemesis. Also has catheter induced blood clot. Admit to L&D for another PICC.
5. 69 yo F had outpatient renal US and showed possible aortic dissection flap. Rads sent in for angio. Angio neg. d/c
6. 75 yo F has LH and nausea. Just hospitalized a few days ago for mild type 2 MI. Eveyrthing is normal but didn't want to go home until she was "back to normal." Took several hours of nonsense interventions but she got better. "I'm getting better! I'm not dead yet!" d/c
7. 75 yo F with symptomatic afib 110-130. She feels palpitations. Marked dyspnea on exertion. Labs, CXR, dilt x2, metop, and admit.
8. 60 yo F with chronic pancytopenia (from MDS) has b/l leg cellulitis. Labs OK. admit
9. 64 yo F with trach from anaplastic thyroid cancer has cellulitis around her trach. Standard labs, abx, and admit.
10. 27 yo M with DM has FSG 700, colitis and ascites. Weird combo. admit.
11. 21 yo F fainted while starting a job today. EKG normal. vasovagal syncope. d/c
12. (signout) 80 yo F with left facial droop. Likely bells and asked to f/u MRI. MRI neg. d/c
13. 74 yo M with foley problems, possibly leakage. Nurse twiddled the foley. Bladder empty on US. d/c
14. 70 yo F p/w leg cellulitis, just discharged 3 days ago for same thing. Home health nurse sent her in to be "evaluated". Eval performed and no medical emergency. f/u PCP/podiatry. d/c
15. (signout) 9 yo F with asthma and hypoxic 84%. Required a lot of treatment but eventually got much better. She never appeared sick. d/c O2 was 93-94%. Spend about 10 hrs total in ED. d/c
16. 75 yo M with CP. No CP in ED, EKG and two trops neg. HEART 3? maybe 4? I don't really remember. d/c for PCP workup.
17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago."
18. 25 yo F with brief RUQ pain. Feeling better. Probably her fatty liver causing her problem. d/c
19. 74 yo M, regularly drunk, brought in on 5150 because he shoved his wife and made bad comments about her. He is drunk today. Wow how about that. asked SS to take care of this case. presumably discharged on a subsequent shift.
20. 16 yo F hurt BOTH ankles playing volleyball. Both are not broken. She was able to hop out of the ED on her better ankle. I gave her a high-five in front of her parents and said "you are going places my dear! You are a keeper!" She smiled and was obviously very happy with the outcome. d/c
21. 48 yo F sent in by PCP for Hg 5. She gets post-coital bleeding and prior notes suggests she has a cervical mass. I said "Please no more sex until you get this fixed" and she smiled. She wasn't bleeding in the ED. after pRBC and IV iron sucrose, d/c
22. 13 yo F with no BM for 5 days. Rx 4 different medicines to make her to poop! d/c
23. 15 yo F with traumatic foot pain, has broken 5th metatarsal. d/c
24. 30 yo M with post-surgical wrist pain. exam benign, XR stable. d/c
25. 38 yo M with LBP and scrotal pain. Exam, UA, and scrotal US are OK. He was very comfortable. d/c
26. 43 yo F with traumatic pinky toe pain. It's broke. d/c
27. 42 yo F has broken qtip in her ear. I pulled it out. d/c
Wish I could go back in time to 1980 and see what a day in the life was like for ER docs.
Side question: maybe she looked proper miserable (and not just whiny and miserable) and that merited the narcs, but is it common for you (or others here) to give a day or two of narcotics for "unidentifiable source pain?" At my shop, basically no one does that. This lady would have gotten a shot of toradol and maybe an rx for flexeril / lidoderm if MSK was suspected, but definitely nothing controlled. Our whole group has more or less adopted that philosophy and I feel it keeps a lot of the drug seekers at the ER across town.17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago."
I think I would consistently not like horse manure shoveling.
Lately most of what I do (midnights) once I’ve worked down the somatic nonsense in the waiting room is try to dispo the psych patients in the waiting room. Otherwise they get covid sitting out there and become undispoable. We don’t have a social worker and the nurses usually only sort of try. Tonight this work was interrupted by a perforated viscus (waiting room), a PE (waiting room), a stroke alert (in back), a peds asthma resp distress I sent to the hospital that has a picu on nRB (waiting room again), and a nursemaid elbow. Still, I was able to get 2 admitted to psych hospital , one sent to the crisis home and one to the friendly local drunk tank. Lol what a life
Variable and dependent on the patient and my mood. I generally fight patients on NOT giving narcs. On the spectrum of "I never give narcs (which I don't believe when people espouse this)" to "I don't give a F I give them all the time" I'm probably in the -1.0 STD because...as we know...it is a normal distribution variable. LOL
That relatively annoying pt I wanted out of the ER so fast I did not hesitate to write for 6 pills (the "I don't give a F Rx" is norco 5-325 TID PRN pain dispense 6)
12-hour overnight fun:
1. 68 F - COPD power level of *OVER 9000*. Haircut like Vegeta from DragonBall-Z. Admit.
2. 48 M - Fall and headbonk on Xarelto. Everything is drama. Brought his mommy. DC.
3. 37 F - Migraine again. "Here's my note from my SPECIAL neurologist that says I should get DILAUDID." DC.
4. 76 F - Accidentally took an extra Tramadol 50mg tablet. Is terrified she's going to die. Not today - but soon, honey. Keep those rosary beads warm. This got dark. I'm sorry that I wrote that. DC.
5. 92 F - Vomiting x1. Doesn't know what galaxy this is. UTI. DC. Family won't come pick her up. Yes, you will. DC.
6. 88 M - Mechanical fall from stepping off of curb too fast. DOAC on board. CT cantaloupe/celery stick normal. DC.
7. 14 F - Fever and headache. Home COVID test positive. Mom "isn't sure what that means, so brought her here". DC.
8. 91 M - Transfer from Hee-Haw Regional for stroke. Admit.
9. 71 M - On home hospice care and "not waking up". Family scared he might die. SPOILER ALERT: He will. Admitted to hospice.
10. 29 M - MVC with seat-belt contusion. Too fat to care. May have tried to eat damaged sedan. DC.
11. 9 M - Fever. COVID+. DC.
12. 14 F - Fever and sore throat. No fever or sore throat. Mom requests work note. DC.
13. 44 M - Chest pain. Cath'ed 2 days ago. Troponin is actually *OVER 9000*. EKG changes. Admit.
14. 3 M - Fussy. Mom says he plays with his penis too much. "Listen, lady - I'm 40 years old; that never stops." DC.
15. 35 F - "VP Shunt headache" (we have a LOT of these at NewJob). Call to her neurosurgeon. "Again?!" DC.
16. 67 M - Stroke alert. LVO on CTA. I didn't even perform a physical exam. Kinda. Admit.
17. 41 F - RUQ pain for 1 day. Shamu-caliber obesity. Workup overwhelmingly negative. So fat she slurs her words because the InceptChin ("Inception-Chin") stops her from fully opening her mouth. DC.
18. 76 F - Near-syncope. Rx List: Percocet. Valium. Ativan. Tramadol. ETOH = 212. Sassy! Call me, maybe. DC.
19. 87 F - Abdominal pain. No abdominal pain. Thinks Nixon is the president. Workup negative. DC.
20. 69 F - Took CBD gummy from bottle given to her by friend prior to sleep. Now afraid to go back to sleep, certain that she will die. Label says: "50mg High Purity Delta-8 THC". On a scale from "1" to "Cheech", she was "Chong". Counseled on reading comprehension. DC.
21. 86 M - Found by wife in blood/emesis pool on floor of home. Aspiration pneumonia. INR = 5.2. Admit.
22. 58 M - "Wants rehab placement". Refused rehab placement. DC.
23. 39 M - End-stage liver disease/alcohol withdrawal. On a scale from "1" to "Canary", he was "School Bus". Admit.
24. 85 M - Spreichen sie Deutch? NO! Signed out to oncoming physician. Don't even know what the chief complaint was.
1. 68 F - COPD power level of *OVER 9000*. Haircut like Vegeta from DragonBall-Z. Admit.
2. 48 M - Fall and headbonk on Xarelto. Everything is drama. Brought his mommy. DC.
3. 37 F - Migraine again. "Here's my note from my SPECIAL neurologist that says I should get DILAUDID." DC.
4. 76 F - Accidentally took an extra Tramadol 50mg tablet. Is terrified she's going to die. Not today - but soon, honey. Keep those rosary beads warm. This got dark. I'm sorry that I wrote that. DC.
5. 92 F - Vomiting x1. Doesn't know what galaxy this is. UTI. DC. Family won't come pick her up. Yes, you will. DC.
6. 88 M - Mechanical fall from stepping off of curb too fast. DOAC on board. CT cantaloupe/celery stick normal. DC.
7. 14 F - Fever and headache. Home COVID test positive. Mom "isn't sure what that means, so brought her here". DC.
8. 91 M - Transfer from Hee-Haw Regional for stroke. Admit.
9. 71 M - On home hospice care and "not waking up". Family scared he might die. SPOILER ALERT: He will. Admitted to hospice.
10. 29 M - MVC with seat-belt contusion. Too fat to care. May have tried to eat damaged sedan. DC.
11. 9 M - Fever. COVID+. DC.
12. 14 F - Fever and sore throat. No fever or sore throat. Mom requests work note. DC.
13. 44 M - Chest pain. Cath'ed 2 days ago. Troponin is actually *OVER 9000*. EKG changes. Admit.
14. 3 M - Fussy. Mom says he plays with his penis too much. "Listen, lady - I'm 40 years old; that never stops." DC.
15. 35 F - "VP Shunt headache" (we have a LOT of these at NewJob). Call to her neurosurgeon. "Again?!" DC.
16. 67 M - Stroke alert. LVO on CTA. I didn't even perform a physical exam. Kinda. Admit.
17. 41 F - RUQ pain for 1 day. Shamu-caliber obesity. Workup overwhelmingly negative. So fat she slurs her words because the InceptChin ("Inception-Chin") stops her from fully opening her mouth. DC.
18. 76 F - Near-syncope. Rx List: Percocet. Valium. Ativan. Tramadol. ETOH = 212. Sassy! Call me, maybe. DC.
19. 87 F - Abdominal pain. No abdominal pain. Thinks Nixon is the president. Workup negative. DC.
20. 69 F - Took CBD gummy from bottle given to her by friend prior to sleep. Now afraid to go back to sleep, certain that she will die. Label says: "50mg High Purity Delta-8 THC". On a scale from "1" to "Cheech", she was "Chong". Counseled on reading comprehension. DC.
21. 86 M - Found by wife in blood/emesis pool on floor of home. Aspiration pneumonia. INR = 5.2. Admit.
22. 58 M - "Wants rehab placement". Refused rehab placement. DC.
23. 39 M - End-stage liver disease/alcohol withdrawal. On a scale from "1" to "Canary", he was "School Bus". Admit.
24. 85 M - Spreichen sie Deutch? NO! Signed out to oncoming physician. Don't even know what the chief complaint was.
Did cards or hospitalist admit that pt? I can just imagine "of course the trop is sky high - we were just mucking around in there!" The EKG changes, that had to be the money.
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I don’t know .. sounds kind of average shift to me .. maybe thats my Stockholm syndrome shining through.
Appreciate the massively obese mva story. While ago I had a girl shot at short range rlq (walked in, we are level 3 TC) thankfully she was so obese that the bullet just ricocheted around the fat and ended up in the left flank area - there was a visible air tract through subQ tissue. Amazing.
I enjoy the scales 1 to whatever. Please keep them coming.
@VA Hopeful Dr
You need to post what you see in one day.
You need to post what you see in one day.
I can, but are y'all actually interested in what a day of outpatient FM looks like?
I’m actually am … I’m curious what the overlap is like. My impression is that ambulatory medicine basically never sees sick people or people in pain. I know that’s not true, but a lot of people have written things like that.
Most definitely. My wife is a PCP, but still interesting to see the other side of the equation.
Hospitalist did. I called cards and said: "Hey. Here's what's up. Yes, I read the cath lab report. It's... Curious. Got no pushback.
data point- I grew up in BFE midwest- town of 700 - we had a general practioner doctor in town that was probably 60 years old back in the 80's. He was all excited that he got to deliver triplet at our local hospital (now a critical access hospital) that has maybe 25 beds. Now in 2022 our gigantic city hospital that average like 18 births a day generally defers those patients to the local academic medical center.
Fair enough. Today is my half day so its truncated a bit:
28 yo refill of anxiety meds, wants to come off of them so discussed how to wean to prevent withdrawal from SSRI. Technically obese so doing lipid and DM screening.
53 yo DM/HTN/lipid/gout follow up. All doing well, refilled all meds and ordered standard labs. Microalbuminuria found, added Jardiance for renal protection. Also bugged about getting a tetanus shot (I've been pushing that hard of late as I had a case of lockjaw back in May that's got me scared).
40 yo gout f/u. No flares since last visit. Refilled and repeated labs.
37 yo no show. Our policy is 3 no shows in a rolling 12M period warrants dismissal. He runs 3 no shows in 17 months consistently for 2 years. If he has another no-show between now and 2024 he's getting dismissed. Office manager on board.
57 yo hospital f/u from hip replacement. Healing well, even 2 week post op pain less than original OA pain. Happy as a clam, thanks me for picking a good surgeon.
72 yo f/u for HTN/DM/CAD/lipid. All doing well, meds/labs. Big lipoma (6-ish cm) referred to surgery. Allergies worse, add flonase. Thanks me for referring to urology for elevated PSA, biopsies all normal.
43 yo f/u for DM/lipids. Ran out of meds last week, gets mild lecture of calling for refills to prevent this. Obese and wants help, Ozempic to the rescue.
75 yo index finger pain after smashing it between pieces of PVC pipe while drilling a hole in said pipe (this woman is a badass). XR normal. Also recheck lipids/TSH after changing synthroid and lipitor dose 2 months ago.
75 yo neck pain. Left trapezius muscle spasm. Instant relief with trigger point injection. XR neck as well given h/o ACDF. Significant degeneration in remaining discs. Will refer to neurosurgery if any pain after injection.
5 yo fever, cough. Looks OK. RSV positive, supportive care discussed.
94 yo with cough, COVID exposure. COVID+, paxlovid given. CXR OK.
22 yo ED follow up for BPPV. Refer to vestibular rehab. Also with painful jaw nodule for 1 day. Inflammed lymph node. Watch for 3 weeks, if still there will get US.
20 yo with recurrent cerumen impaction. Nurse irrigated. I spent total 70 seconds with him. Leaves happy.
70 yo with elevated BP at dentist. Elevated in office. Start BP meds. RTC in 2 weeks, has cataract surgery in 1M, doesn't want it to get postponed. Reassured we can handle this.
Got to work at 7:55am, walked out at noon.
myocardinal infarction
New Member
Fourth year resident here and enjoy this thread. 8-hr moonlighting shift in our fast track area
1) 29 M w/ ear pain and sinus congestion. Ears nl. DC w/ flonase
2) 48 F sciatica flare after bending over to pick something up. Meds and DC
3) 71 F c/o neck pain. Everyone else avoiding the pt because "OMG old person with neck pain". Very musculoskeletal on exam/history. Meds and DC
4) 46 M w/ autoimmune disease history presenting w/ chest pain/SOB and every complaint imaginable x1 week. Amazingly not an emergency until he was arrested this morning. Labs/EKG/CXR nl. Tell him he's discharged and he starts tearing suction canisters/oxygen off the wall and slamming himself into the wall and stretcher trying to injure himself. Cop stands there and just watches....RN hits panic button over and over and security doesn't receive it. Finally I wrangle security to restrain him while the officer handcuffs his other hand to the bed. Now screaming his hand is broken. It isn't. DC
5)71 F with all over pain since fall 6 months ago. Meds dc
6) 68 F w/ MCP swelling after hyper extending finger putting on underwear. XR shows arthritis. Finger splint and given ortho number. DC
7) 36 M with all over pain after MVC. Chased the driver of other car down with no problem. Now can't walk or turn his head at all. Demanding x-rays. Proceeds to walk all over the ED completely fine to yell about his wait time and that he feels no better. Left prior to x-ray reads. DC
8) 52 F with 4 days traumatic bilat biceps/thigh pain. Rpt visit so sent BMP/CPK that were nl. Felt much better after meds. DC
9) 32 to M w/ palps/near syncope at work this morning. Tachy to 120s. Heavy Etoh last night. New RBBB on EKG. Labs/dimer negative. DC after IVF.
10) 22 F w/ palpitations/SOB/chest pain x2 weeks since COVID dx. Went to UC who did an EKG they said showed short PR int and delta wave and referred to the ED. EKG they sent with her had neither a short PR int or a delta wave....EKG here nl. Labs/dimer negative. DC
11) 73 F itching all over. Urticarial rash. DC w/ benadryl/hydrocort ointment.
12) 24 F woke up with neck pain. Meds->DC
13) 28 M w/ epigastric "bubbling" x months. Abd completely nontender. Outpt US canceled due to insurance issue. US neg. Labs nl. DC
14) 24 M here for 1 staple removal placed 2 weeks ago after being pistol whipped. DC
15) 23 M 5 days post-op rhinoplasty after being punched. Ran out of pain meds last night. ENT refilled but when he got to pharmacy they hadn't gotten a script. Called ENT again who told him to go to the ER for pain meds. Almost consulted ENT to make them come see that BS.
16) 58 F ankle pain after MVC last night. XR neg. DC
17) 38 M ankle pain/swelling after twisting it. Signed out to night team. Probably sprained.
18) 60 M homeless. Hit with rock in back of head 10+ hours ago. Meds and dc.
19) 69 F with atraumatic red eye since this afternoon after using eye drops. UC told her she had a hyphema and nonreactive pupil and should go to the hospital by ambulance. Pupils reactive. Subconjunctival hemorrhage....which is rare SE of her drops. In fairness it was basically her entire sconjunctiva so kinda see how an UC PA/NP might freak out. Counseled to hold eye drops and discuss with her ophtho. DC
20) 81 F w/ urticarial rash. Meds and DC.
21) 32 F w/ neck pain x 24 hours started while picking up something off floor. Looks like torticollis. Seen night prior by PA and given toradol/valium/morphine... CTA was ordered. Walked out waiting for scan. Now back and wants scan. Signed out to night team. CTA wound up negative...surprise
1) 29 M w/ ear pain and sinus congestion. Ears nl. DC w/ flonase
2) 48 F sciatica flare after bending over to pick something up. Meds and DC
3) 71 F c/o neck pain. Everyone else avoiding the pt because "OMG old person with neck pain". Very musculoskeletal on exam/history. Meds and DC
4) 46 M w/ autoimmune disease history presenting w/ chest pain/SOB and every complaint imaginable x1 week. Amazingly not an emergency until he was arrested this morning. Labs/EKG/CXR nl. Tell him he's discharged and he starts tearing suction canisters/oxygen off the wall and slamming himself into the wall and stretcher trying to injure himself. Cop stands there and just watches....RN hits panic button over and over and security doesn't receive it. Finally I wrangle security to restrain him while the officer handcuffs his other hand to the bed. Now screaming his hand is broken. It isn't. DC
5)71 F with all over pain since fall 6 months ago. Meds dc
6) 68 F w/ MCP swelling after hyper extending finger putting on underwear. XR shows arthritis. Finger splint and given ortho number. DC
7) 36 M with all over pain after MVC. Chased the driver of other car down with no problem. Now can't walk or turn his head at all. Demanding x-rays. Proceeds to walk all over the ED completely fine to yell about his wait time and that he feels no better. Left prior to x-ray reads. DC
8) 52 F with 4 days traumatic bilat biceps/thigh pain. Rpt visit so sent BMP/CPK that were nl. Felt much better after meds. DC
9) 32 to M w/ palps/near syncope at work this morning. Tachy to 120s. Heavy Etoh last night. New RBBB on EKG. Labs/dimer negative. DC after IVF.
10) 22 F w/ palpitations/SOB/chest pain x2 weeks since COVID dx. Went to UC who did an EKG they said showed short PR int and delta wave and referred to the ED. EKG they sent with her had neither a short PR int or a delta wave....EKG here nl. Labs/dimer negative. DC
11) 73 F itching all over. Urticarial rash. DC w/ benadryl/hydrocort ointment.
12) 24 F woke up with neck pain. Meds->DC
13) 28 M w/ epigastric "bubbling" x months. Abd completely nontender. Outpt US canceled due to insurance issue. US neg. Labs nl. DC
14) 24 M here for 1 staple removal placed 2 weeks ago after being pistol whipped. DC
15) 23 M 5 days post-op rhinoplasty after being punched. Ran out of pain meds last night. ENT refilled but when he got to pharmacy they hadn't gotten a script. Called ENT again who told him to go to the ER for pain meds. Almost consulted ENT to make them come see that BS.
16) 58 F ankle pain after MVC last night. XR neg. DC
17) 38 M ankle pain/swelling after twisting it. Signed out to night team. Probably sprained.
18) 60 M homeless. Hit with rock in back of head 10+ hours ago. Meds and dc.
19) 69 F with atraumatic red eye since this afternoon after using eye drops. UC told her she had a hyphema and nonreactive pupil and should go to the hospital by ambulance. Pupils reactive. Subconjunctival hemorrhage....which is rare SE of her drops. In fairness it was basically her entire sconjunctiva so kinda see how an UC PA/NP might freak out. Counseled to hold eye drops and discuss with her ophtho. DC
20) 81 F w/ urticarial rash. Meds and DC.
21) 32 F w/ neck pain x 24 hours started while picking up something off floor. Looks like torticollis. Seen night prior by PA and given toradol/valium/morphine... CTA was ordered. Walked out waiting for scan. Now back and wants scan. Signed out to night team. CTA wound up negative...surprise
Good times. You think 19 was just a subconjunctival hemorrhage from using eyedrops? Sounds unlikely. Funny she didn't have a hyphema NOR a nonreactive pupil.
myocardinal infarction
New Member
It was restasis, which I looked up, and apparently can sometimes cause subconjunctival hemorrhage. She'd had the same thing happen twice before both after using restasis.
Pod blocked night shift where nothing in the department was moving because we had 20 boarded patients in our area:
1) 78yo M 4 days LLQ pain and hematuria. CTd, turns out the guy has a new Cecal mass that eroded into his kidney. Pooping into GU system. Septic. Admitted for IV abx and possible surgery.
2) 44F with 3 years of abdominal pain. Says it got worse yesterday. Allegedly got “admitted to OSH for a liver infection” discharged 5 days ago. Afebrile, CT/US negative, labs pristine, discharged.
3) 22F, took misoprostol at home yesterday for induced AB. Terrible pain, vomiting, and bleeding. US shows incomplete AB, Hb stable. Discharged with pain meds to complete the AB at home, syncopized in the lobby and got rushed back in. Dropped her Hb 2 points, admit to obs unit for serial hemoglobins and pain control.
3) 83 yo male, in “SVT” per EMS. They shocked him, he got combative, so they hit him with 5 of versed and shocked again. EKG In ED shows sinus tach. Family says do everything. Obtunded from versed, de satting, intubated. Septic from a UTI. BP 50/35, lined and levo. MICU refuses to admit, says extubate him in ED and admit to floor. MICU director called. Signed out pending suits getting involved.
4) 58 yo M with 1 day of epigastric pain. CT negative. Better with famotidine. Discharged
5) 48 year old female with RUQ pain. US shows cholelithisis. Pain control and DC
6) 40 yo female undocumented, just got here from venezuela, has ESRD. Has been getting cash pay intermittent dialysis through a nasty looking IJ cath during her migrant journey through Central America. BP 250/150, pulmonary edema, K 7. Admit for dialysis and placement of a new catheter.
7) 26M firefighter syncopized while training. Labs and EKG normal. Dc w PCP followup.
8) 36F from the same EMS crew as #3. Of her 8mg daily Xanax + klonopin x3 days. HR 130. Shocked by EMS for SVT. Also in sinus tach. Better with ativan. Admitted for benzo withdrawal.
9) 24F with 20% TBSA burns from cooking with oil. Admitted to burns ICU, pain meds, IVF.
10) 54F with 1 day of sudden RLE weakness, headache, CP, bp 230/something. CTA dissection protocol. Turns out she has a sarcoma of the R pelvis, with Mets to brain, lung, and mediastinum. Midline shift and vasogenic edema on CT. Dex, dilaudid, admit.
11) 35M just got back from a diving trip, R ear pain. Prefer TM with otitis externa. Abx drops and discharge.
12) 26F 6 weeks pregnant with abdominal pain. Subchorionic hemorrhage. Tylenol, dc with OV followup.
1) 78yo M 4 days LLQ pain and hematuria. CTd, turns out the guy has a new Cecal mass that eroded into his kidney. Pooping into GU system. Septic. Admitted for IV abx and possible surgery.
2) 44F with 3 years of abdominal pain. Says it got worse yesterday. Allegedly got “admitted to OSH for a liver infection” discharged 5 days ago. Afebrile, CT/US negative, labs pristine, discharged.
3) 22F, took misoprostol at home yesterday for induced AB. Terrible pain, vomiting, and bleeding. US shows incomplete AB, Hb stable. Discharged with pain meds to complete the AB at home, syncopized in the lobby and got rushed back in. Dropped her Hb 2 points, admit to obs unit for serial hemoglobins and pain control.
3) 83 yo male, in “SVT” per EMS. They shocked him, he got combative, so they hit him with 5 of versed and shocked again. EKG In ED shows sinus tach. Family says do everything. Obtunded from versed, de satting, intubated. Septic from a UTI. BP 50/35, lined and levo. MICU refuses to admit, says extubate him in ED and admit to floor. MICU director called. Signed out pending suits getting involved.
4) 58 yo M with 1 day of epigastric pain. CT negative. Better with famotidine. Discharged
5) 48 year old female with RUQ pain. US shows cholelithisis. Pain control and DC
6) 40 yo female undocumented, just got here from venezuela, has ESRD. Has been getting cash pay intermittent dialysis through a nasty looking IJ cath during her migrant journey through Central America. BP 250/150, pulmonary edema, K 7. Admit for dialysis and placement of a new catheter.
7) 26M firefighter syncopized while training. Labs and EKG normal. Dc w PCP followup.
8) 36F from the same EMS crew as #3. Of her 8mg daily Xanax + klonopin x3 days. HR 130. Shocked by EMS for SVT. Also in sinus tach. Better with ativan. Admitted for benzo withdrawal.
9) 24F with 20% TBSA burns from cooking with oil. Admitted to burns ICU, pain meds, IVF.
10) 54F with 1 day of sudden RLE weakness, headache, CP, bp 230/something. CTA dissection protocol. Turns out she has a sarcoma of the R pelvis, with Mets to brain, lung, and mediastinum. Midline shift and vasogenic edema on CT. Dex, dilaudid, admit.
11) 35M just got back from a diving trip, R ear pain. Prefer TM with otitis externa. Abx drops and discharge.
12) 26F 6 weeks pregnant with abdominal pain. Subchorionic hemorrhage. Tylenol, dc with OV followup.
Nearly died laughing at these (with the first one, it was laughter mixed with "oh no's" and "JEEZUS"). I've got a local EMS crew that calls STEMIs on every LBBB. Saw them a couple times yesterday.
What the F is wrong with your hospital re: your second #3.
What is wrong with your MICU
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I don't think your EMS crews should be allowed to have a defib. Honestly, just replace it with an AED.
Academic county hospital. Some people just don’t want to do their job.
I love it here because it’s a lot of working poor patients that are very grateful for their care and you can do quite a bit of good if the system is manipulated correctly. But also all the BS that comes with county/unions/etc and the annoying burnt out holier than thou subspecialists who think they’re gods gift to modern medicine.
Its simply a failure of the hospital AND ER admin to allow that to happen. You have an intubated patient on a pressor and where does the attending think that patient is going to go? Just stay indefinitely in the ED?
I would write up that MICU attending!
What happened to that patient anyway?
Escalated to department chairs, MICU chair apologized for his fellows behavior and placed admit orders himself. So a reasonable outcome, albeit with a few phone calls and 8 hours in the ED waiting for orders.
Our medical director was livid.
The issue is a recurring one this time of year/in general. We take a LOT of Latin American IMGs for residency and fellowship in medicine/surgery. Where they trained outside the US, the ER is usually still someone who flunked out of or never did a residency, and basically functions just to triage people to other specialities, but doesn’t have the power to make dispo decisions or do critical interventions. I distinctly remember one fellow being visibly shocked to find out we even do airways, and calling her on call attending at 3am, in the resus bay, to confirm the ED was allowed to intubate.
It usually takes a few chastisements but their department heads before they realize in America emergency medicine is it’s own speciality with its own body of knowledge. And of course there’s always the nighthawks who will do everything possible to push a dispo off until 7am when they do home and the day team arrives.
Oh and the patient was fine. He went to the ICU, was extubated to bipap that evening, and is now in the IMCU Getting weaned off his levo drip.
1) what in the actual F. What is the MICU for then!?
2) not long ago had a guy with sinus tachycardia to 180.. ems had given adenosine 6/12/12 and shocked him twice .. i said (squinting at the monitor) idk I think there’s P Waves .. the medics say Yeah there were definitely p waves on our 12 lead! 🤦🏻♀️
I had another one last night with a guy who was 35, on methotrexate for RA, came in for SOB/CP, endorses doing some coke 3 days ago at a party.
Trop (from triage) was 0.65. For reference our upper limit of normal is 0.033. Medicine refuses to admit because “it’s probably just the cocaine I don’t know what we even would do for him, he can get an echo outpatient. Methotrexate is cardioprotective.”
Ma’am a trop 20x the upper limit of normal needs to be investigated. Healthy 35 year olds without heart disease shouldn’t bump a trop like that just from a bit of demand ischemia.
The last STEMI that I sent to the cath lab was a 34 year old female. Stented the LAD.
Looks like you are in residency? Do you guys have admitting privileges? I remember when I was in residency, the ER could admit anyone. Now...obviously that led to nonsense admissions, but we certainly didn't have to deal with that crap above.
At least you guys can order/demand a consult from medicine. They have to come per EMTALA. The question to them is "Does this patient need admission?" They have to put in a note and you can tell the patient "It's not me denying you admission, it's them" and if you guys get dragged to court you can say "I tried as hard as I could to admit that patient"
I keep reading about EMS shocking patients for "SVT" and I have to ask...why the urgency to shock? Were these patients hypotensive, or is your guys' EMS crews that trigger-happy?
Yeah, lots of trigger happy EMS crews out there
Yea we do, there’s just certain medicine residents who at night will work very hard not to admit. And there’s no in house attending at night to set them straight.
The way our program is set up it’s a hybrid with some time at a big academic county hospital where people will try to get away with all sorts of shenanigans, and then the rest of the time at a smaller community hospital where admitting to medicine gets you an IM attending who at worst may say “hey I’ll happily admit but just so you know there’s not much role for an inpatient work up here.”
We have a couple rigs that very much like to “stay and play.” They’ll do all sorts of weird stuff like shock people, run codes in the field for extended periods while trying to pace PEA or running dopamine drips in cardiac arrest. It’s really strange and always the same 1-2 rigs, with the same 1-2 really old captains who’ve been around since Miami rose from the sea but haven’t touched a textbook in decades.
Not an entire shift, but this case was pretty wack. Urgent care affiliated with my shop's hospital system calls about a transfer to the ED for a stroke workup. 35 year old lady, obese and pre-diabetic, presented with about an hour of "right arm numbness." No other deficits. A very cursory glance at the EMR that the UC doc and I both had access to shows that this lady presented to the ED a week ago with the same complaint. Whatever though. That obviously doesn't rule out CVA on its own. I see her 20 minutes later. On further questioning, she reveals it's really paresthesias, and only affecting a dermatolomal distribution. Also revealed that the symptoms have been subacute in duration and intermittent. Only went to UC because she's frustrated that she hasn't had an answer yet. NIHSS: goose egg. I told her she didn't need a CT or really any ED workup. Very understanding and pretty pleasant. We obs'ed her for 2 hours and her symptoms improved. Discharge with PCP followup instructions and peripheral neuropathy diagnosis. Recommended outpatient MRI.
I try really hard to be understanding of referrals to the ED since I'm a very conservative physician and pretty anxious of bad outcomes. But damn if this didn't get me real annoyed. A 5-minute history and physical effectively rules out an acute central process in this lady. It just reeked of laziness and/or punting the ball to the ED.
I try really hard to be understanding of referrals to the ED since I'm a very conservative physician and pretty anxious of bad outcomes. But damn if this didn't get me real annoyed. A 5-minute history and physical effectively rules out an acute central process in this lady. It just reeked of laziness and/or punting the ball to the ED.
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I wish our urgent cares would be that reasonable… we get people sent over for an LP due to fever and headache…. With sore throat, rhinorrhea, cough, body aches, and literally every URI symptom. NO YOU DONT NEED A TAP FOR A COLD!!! “But their swabs were negative!” Yeah, for the three viruses you can test for, when there are literally thousands out there…
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I've had more than a few shifts in the past two years in which I could transfuse 4 units and discharge faster than I could admit.
At least yours will do a swab. We got one from ours last shift with all the URI symptoms + diarrhea. All they did was a UA and said the didn't have a UTI. So they came to us and dun, dun, dunnnnnn: COVID. Now they're too far out for Paxlovid
oh noes
Let’s get this party started again from everyone’s favorite county hospital dumpster fire of a Saturday shift
1) 67M L flank pain - left kidney stone. He’s a pharmacist. Nice guy
2) 44F very impressive panic attack. So impressive law enforcement PCd her. Labs normal, admitted for psych.
3) 49F sent from jail for HR of 140. Now with HR of 120, sinus. Labs stone cold normal. HR won’t budge with fluids. Can’t go for CTA because there’s no guard from corrections to escort the patient. Admitted to medicine, hopefully they’ll have a guard available by the AM for the CTA.
4) 37M fell off a roof —> a humerus fracture. DC with percs, a sling, a referal to our orthos.
5) 60M undocumented without insurance with lung cancer with Mets to spine and liver. Worsening pain. Gave him percs and offered admission for pain control. He declines, dc.
6) 60M with ESRD undocumented without insurance came to US to get dialysis because he couldn’t afford it in his home country. K 6.9, peaked Ts. Meds & Admit. Will repeat this cycle indefinitely
7) 61F chest pain leg swelling. Tons of risk factors. Labs and CTA normal. Admit for ACS rule out
8) 53M with ESRD got here from the Bahamas 1 month ago. Same deal as above. Labs normal, no dialysis today.
9) 50M with hematuria for 1 year. Had a surgery in Jamaica that showed some kind of cancer. Just “here on vacation but now can’t afford to get home”. labs normal, US with huge renal mass. Discharged with info for free county insurance.
10) 51F with cellulitis of LE. Discharged
11) 34M with cerebral palsy and hypoxia. Just discharged 2 days ago after MDR pneumonia. Admit for more antibiotics.
12) 77F with hypoxia, only hx is of DM2. Wheezy with CO2 on the gas >100. Progressively more somenolent. Desatting to the 40s on bipap. Intubated —> ICU.
13) 61F with afib RVR and BGL 600. Hx CHF. No DKA. Admitted to IMCU. Off All meds x1 month...
14) 60M from LTACH w/ hypoxia. New ICH in an old ischemic stroke, new PE with R heart strain, recurrence of prior SAH as well. ICU NP declines admission and refuses to evaluate patient because “what is their ICU need, what would we even do for this.” Writes a note naming me saying I didn’t correctly present the patient or communicate the clinical picture. Still won’t admit Boarded in ED for the rest of the shift.
15) 52F metastatic breast cancer with Mets to spine. No insurance, ran out of pain meds. Dilaudid x4, admitted for pain control.
16) 37M with new onset blindness x3 months. Sent to ER from ophthalmology for emergent LP to rule out pseudotumor/IIH. BMI 45, needle not long enough to reach spine. Admitted for LP with IR.
17) 20M homeless, meth abuse, pseudo seizures, type 1 DM, transplanted kidney done at facility in another state. Off all transplant meds and insulin x2 weeks. Just got to Miami on the greyhound. In DKA and acute renal failure. Admitted to IMCU.
18) 43M who got gold tooth plating done in Mexico but the gold was fake and it destroyed his teeth. Now his teeth hurt. He has dental insurance but can’t figure out how to navigate their phone tree to see a dentist. Motrin & Discharged.
19) 57M previously healthy now with shaking chills, tachy 140, lactic 5, fulminant renal failure, 40 degree fever, no obvious source of infection. Maybe rheum? Who knows. Dialysis cath, admit.
20) 60M with COPD now with new onset heart failure. Satting 65%. Bipap —> admit to IMCU. No beds available. Board in ED x12 h. Exposed genitals to pt 3, tried to pee on them because their phone was too loud. Restraints and PC’d.
21) 57M DM2, LLE swollen and hot. Nec fasc. Abx & Straight to OR with GS.
22) 42F w/ RUQ pain. US negative. Found to have new DM2. BGL 500. MFM and DC.
23) 54F who fell off a chair 1 month ago and her butt hurts. XRs show osteoarthritis. Naproxen DC.
24) 60F w RLQ pain. Appy scan —> ovarian cancer with Mets. Uninsured. Called our gyn oncs and got her a free clinic visit to at least start the workup while she gets insurance.
25) 50F w/ headache x2 weeks. Hx pancreatic cancer s/p whipple done in Nicaragua. CTB with no major Mets. Migraine cocktail and DC.
26) 89M with metal mechanical heart valve done in Panama. On warfarin, 5x syncope, bright red blood per rectum, HR 150, BP soft. No monitored hall beds available. Put my personal pulse ox on his hand and put him in a chair by the Doc desk. Transfused, GI called, refuses consult without charted vitals, but nurse is on break. I chart my own vitals and GI comes. Nowhere to do a rectal exam. Dispo is ICU but no beds available. He stays in his folding chair until a hall bed opens up.
27) 28F normal appearing female found wandering in a luxury apartment complex attempting to fight people. No psych history. Says she was sent here from England to save America. PCd and transfer to psych for w/u new onset psychosis.
28) 71M nursing home dude with recent perf, bowel necrosis, ex lap, and ostomy. Septic from pyelo today. Admitted.
1) 67M L flank pain - left kidney stone. He’s a pharmacist. Nice guy
2) 44F very impressive panic attack. So impressive law enforcement PCd her. Labs normal, admitted for psych.
3) 49F sent from jail for HR of 140. Now with HR of 120, sinus. Labs stone cold normal. HR won’t budge with fluids. Can’t go for CTA because there’s no guard from corrections to escort the patient. Admitted to medicine, hopefully they’ll have a guard available by the AM for the CTA.
4) 37M fell off a roof —> a humerus fracture. DC with percs, a sling, a referal to our orthos.
5) 60M undocumented without insurance with lung cancer with Mets to spine and liver. Worsening pain. Gave him percs and offered admission for pain control. He declines, dc.
6) 60M with ESRD undocumented without insurance came to US to get dialysis because he couldn’t afford it in his home country. K 6.9, peaked Ts. Meds & Admit. Will repeat this cycle indefinitely
7) 61F chest pain leg swelling. Tons of risk factors. Labs and CTA normal. Admit for ACS rule out
8) 53M with ESRD got here from the Bahamas 1 month ago. Same deal as above. Labs normal, no dialysis today.
9) 50M with hematuria for 1 year. Had a surgery in Jamaica that showed some kind of cancer. Just “here on vacation but now can’t afford to get home”. labs normal, US with huge renal mass. Discharged with info for free county insurance.
10) 51F with cellulitis of LE. Discharged
11) 34M with cerebral palsy and hypoxia. Just discharged 2 days ago after MDR pneumonia. Admit for more antibiotics.
12) 77F with hypoxia, only hx is of DM2. Wheezy with CO2 on the gas >100. Progressively more somenolent. Desatting to the 40s on bipap. Intubated —> ICU.
13) 61F with afib RVR and BGL 600. Hx CHF. No DKA. Admitted to IMCU. Off All meds x1 month...
14) 60M from LTACH w/ hypoxia. New ICH in an old ischemic stroke, new PE with R heart strain, recurrence of prior SAH as well. ICU NP declines admission and refuses to evaluate patient because “what is their ICU need, what would we even do for this.” Writes a note naming me saying I didn’t correctly present the patient or communicate the clinical picture. Still won’t admit Boarded in ED for the rest of the shift.
15) 52F metastatic breast cancer with Mets to spine. No insurance, ran out of pain meds. Dilaudid x4, admitted for pain control.
16) 37M with new onset blindness x3 months. Sent to ER from ophthalmology for emergent LP to rule out pseudotumor/IIH. BMI 45, needle not long enough to reach spine. Admitted for LP with IR.
17) 20M homeless, meth abuse, pseudo seizures, type 1 DM, transplanted kidney done at facility in another state. Off all transplant meds and insulin x2 weeks. Just got to Miami on the greyhound. In DKA and acute renal failure. Admitted to IMCU.
18) 43M who got gold tooth plating done in Mexico but the gold was fake and it destroyed his teeth. Now his teeth hurt. He has dental insurance but can’t figure out how to navigate their phone tree to see a dentist. Motrin & Discharged.
19) 57M previously healthy now with shaking chills, tachy 140, lactic 5, fulminant renal failure, 40 degree fever, no obvious source of infection. Maybe rheum? Who knows. Dialysis cath, admit.
20) 60M with COPD now with new onset heart failure. Satting 65%. Bipap —> admit to IMCU. No beds available. Board in ED x12 h. Exposed genitals to pt 3, tried to pee on them because their phone was too loud. Restraints and PC’d.
21) 57M DM2, LLE swollen and hot. Nec fasc. Abx & Straight to OR with GS.
22) 42F w/ RUQ pain. US negative. Found to have new DM2. BGL 500. MFM and DC.
23) 54F who fell off a chair 1 month ago and her butt hurts. XRs show osteoarthritis. Naproxen DC.
24) 60F w RLQ pain. Appy scan —> ovarian cancer with Mets. Uninsured. Called our gyn oncs and got her a free clinic visit to at least start the workup while she gets insurance.
25) 50F w/ headache x2 weeks. Hx pancreatic cancer s/p whipple done in Nicaragua. CTB with no major Mets. Migraine cocktail and DC.
26) 89M with metal mechanical heart valve done in Panama. On warfarin, 5x syncope, bright red blood per rectum, HR 150, BP soft. No monitored hall beds available. Put my personal pulse ox on his hand and put him in a chair by the Doc desk. Transfused, GI called, refuses consult without charted vitals, but nurse is on break. I chart my own vitals and GI comes. Nowhere to do a rectal exam. Dispo is ICU but no beds available. He stays in his folding chair until a hall bed opens up.
27) 28F normal appearing female found wandering in a luxury apartment complex attempting to fight people. No psych history. Says she was sent here from England to save America. PCd and transfer to psych for w/u new onset psychosis.
28) 71M nursing home dude with recent perf, bowel necrosis, ex lap, and ostomy. Septic from pyelo today. Admitted.
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I can feel my blood pressure going up after reading #14.
