Stupidity vs reasonable?

[Annette]

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This has been a very bad week for me. I'd like to hear what you would consider legit.

Last call got an ICU consult from the ED for a patient with a ?SAH. Patient is a 39 year old end stage fibromyalgia patient in for CP/DOE. CP is reproducible with palp and she is scheduled for an outpatient stress echo in the next week. She has been r/o several times already. No EKG changes, no leg edema, fatigue she correlates with stress. "And, oh, by the way, I have this left sided HA" associated with stess. No N/V, changes in vision, not throbbing, better in the dark, but no photophobia, no thunderclap, about the same intensity as her usual ha. Warrents an LP????????

Well, you guessed it- a bloody tap with NO xantho. Neurosurg has zero suspicion for SAH, but get an mri/mra in the am. Would you put this patient in the step down ICU?

I'm a little upset with my attending because he didn't think that the house (end stage fibromyalgia, you know) attending would be comfortable putting this patient on the floor, because she hadn't seen the patient personally! She wouldn't trust the opinion of an ICU attending? A resident I could see. He didn't even call to ask! Is my judgement blurred on this by exhaustion?

 

[jashanley]

What happened to the CT? Was there was one? Was it negative, then she got the tap? Where do you work?
It doesn't even sound like she needed a CT or a tap, but it could atleast look for bleed. That is why you send the 1st and the 4th for tube for cell count and diff if you are concerned. End stage fibromyalgia? I did't know it had an end stage. Who gave her that diagnosis? They make it sound so serious. Even after my rheumatology month, I have yet to hear about end stage fibromyalgia. Wierd diagnosis. Tell her to get more sleep and try some elavil.
It sounds like she has a chronic pain syndrome and frequent headaches (her usual headache to boot).
if the patient had a SAH, yes unit is fine. Most places will put patient's in the unit for "true" suspected SAH. This is one is just odd to me. Chalk it up to a not sick patient filling a unit bed for you. She might bug you for pain meds but she is stable and will likely be you least active patient for the night. Here's to wasting a bed!. How the rest of the week goes better.

 

[DrDre']

What IS end stage fibro? Greater than 11 sensitive points on exam?
You just have to elucidate. My puny brain can not imagine who this disorder could generate to the unit.

 

[Annette]

Sorry about the lack of explinations.

end stage fibromyalgia= "I've tried everything and nothing works and I don't want to get over this because of all the secondary gain, and can you fill out my disablity forms even though I've just met you?"

Head CT was negative.

Thanks for validating my confusion!

 

[spyderdoc]

Sorry about the lack of explinations.

end stage fibromyalgia

Oh my god, that is the funniest "diagnosis" I've ever heard of!!!!
I can't even get myself to believe in "fibromyalgia" to begin with...Now there is an end stage form of this "disease"....
Next thing there will be end stage "irritable bowel syndrome"....I'd hate to be anywhere near that person when they hit end stage!
I wonder what end stage "chronic fatigue syndrome" would be like!

Mark

 

[docB]

This sounds like one of those deals where the whiny pts whines herself into a CT/LP. This often happens when they don't know what saying it's the worst HA of thier lives gets you in the ED. Who knows what she said to the ED doc. The story always changes. Once you make the decision to do the LP and you get the equivocal result you are stuck with it. She gets treated like SAH until proven otherwise. If the ED doc sent her home or sent her to a lower level of care he is screwed. The plaintiff's shyster will ask, "So you had a positive LP and yet you sent my poor client to a step down unit because you still didn't believe her." and next thing you know she's driving the ED doc's car and living at his house. And all the docs saying the pt shoudn't be in the unit will be nowhere to be found.

 

[EMRaiden]

Do they put you on a transplant list for end-stage fibromyalgia?

 

[deleted6669]

yes, they take healthy trigger points from 11 different cadaver donors and graft them in for cure. overnight the patients stop using oxycodone and get jobs. they also stop using paxil/wellbutrin/effexor and lose 200 lbs.

 

[Apollyon]

In all honesty, when I read "end-stage fibromyalgia", I thought it was referring to the primary care docs that had to take care of them.

 

[Katee80]

yes, they take healthy trigger points from 11 different cadaver donors and graft them in for cure. overnight the patients stop using oxycodone and get jobs. they also stop using paxil/wellbutrin/effexor and lose 200 lbs.

Bitter much?

Now make sure you're mean to me too. 😀

 

[spyderdoc]

Bitter much?

Now make sure you're mean to me too. 😀

Stereotypes are made for a reason.... 🙄
The above is a stereotypical "fibromyalgia" patient! Obese, depressed, female, passive aggessive, bad mouths every doctor that she has ever been to...Also has "irritable bowel syndrome" and "chronic fatigue syndrome"...

Anyone care to add any other attributes to the stereotype? I am sure I am missing a few!

Still laughing at the "end stage"

 

[docB]

Stereotypes are made for a reason.... 🙄
The above is a stereotypical "fibromyalgia" patient! Obese, depressed, female, passive aggessive, bad mouths every doctor that she has ever been to...Also has "irritable bowel syndrome" and "chronic fatigue syndrome"...

Anyone care to add any other attributes to the stereotype? I am sure I am missing a few!

Still laughing at the "end stage"

Allergic to toradol, codeine and motrin, gets her "best relief" with 150 of Demerol and 75 of vistiril.

 

[paramed2premed]

On the one hand I am fascinated with the spectrum of disorders that seem to bridge the medical and the psychosocial. The common pathologies reveal a deep connection between mind and brain, and patients deserve not only our respect, but our finest therapeutic skills.

On the other hand, give me a break. The reason this thread is so funny is because its true.

We also forgot to mention; Hypoglycemia, Chronic Lyme, Multiple-chemical Sensitivity, Yeast Syndrome. In males, BACK PAIN.

 

[southerndoc]

On the one hand I am fascinated with the spectrum of disorders that seem to bridge the medical and the psychosocial. The common pathologies reveal a deep connection between mind and brain, and patients deserve not only our respect, but our finest therapeutic skills.

On the other hand, give me a break. The reason this thread is so funny is because its true.

We also forgot to mention; Hypoglycemia, Chronic Lyme, Multiple-chemical Sensitivity, Yeast Syndrome. In males, BACK PAIN.

Are you suggesting that all those diseases are fake or somatic?

 

[deleted6669]

what about chronic abd/pelvic pain s/p hyst/appy/chole/multiple gyn laps. with nl labs/ct/endoscopy/ultrasounds ?

 

[Sessamoid]

What IS end stage fibro? Greater than 11 sensitive points on exam?
You just have to elucidate. My puny brain can not imagine who this disorder could generate to the unit.

"End stage fibromyalgia" is a patient just before s/he's pissed me off enough with pointless, stupid whining to make me want to shoot them in the head. There's your "end stage" right there. While I'm sure that some of those are just patients with organic disease that hasn't yet been diagnosed, the majority of the ones I see are somatisizing or drug seekers. In my dictionary, "fibromyalgia" is nearly synonymous with "drug-seeking anti-winner".

 

[Annette]

I learned something relevent to the headache/cp yesterday!

Apparently with a SAH, there is so much epinephrine released that you can vasospasm your coronary arteries, causing cp. On the EKG, you get big scooped ST segments diffusely. One of the interns had heard it called the scrotal sign.

The MRI/A was negative for bleed.

 

[paramed2premed]

Are you suggesting that all those diseases are fake or somatic?

Fake? No, not at all. I believe that the fibro pt feels actual pain, that the chronic fatigue pt has no energy, that these patients all actually suffer from the insomnia, memory problems, anxiety, and depression that each of these syndromes seems to be defined by. I DO believe that we should respect the patient's description of their symptoms.

I DO NOT believe that we should then leap from this respect for their symptoms to accepting a trendy and politically charged diagnosis. We might do the patient a greater disservice by medicalizing psychosocial problems that do not manifest as classic depression or anxiety.

Oh yeah, thanks empedpa; chronic pelvic pain is another one.