The little things that make you age...

Discussion in 'Emergency Medicine' started by TrumpetDoc, Feb 14, 2017.

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  1. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Abdominal pain case rant.

    0130 hours. 19ym with abdominal pain. 2 days. RLQ, but also RUQ. Really not well localized (yet) but ttp more in RLQ. Very soft abdomen. No guarding. Not a great story for other causes but really lack luster exam.
    Not an exam I'd wake the surgeon for to come see kid.
    I have sent countless folks to surgery based on exam, but this wasn't the kid.
    Labs also norm as they often are.
    Really no worsening exam.
    Talk with him and mom who was with him.
    Basically the return 12-24 hours talk.
    Not really jiving with this. Smiling comfortable and not surgical abdomen.
    In the community you just can't have a surgeon come exam a clinical soft call like this.
    I cannot remember what my exact thinking was. But just a little voice that said he's got something. So we talked over and talked about risks as well as possibility that even with radiation of a CT, this could be benign. Eventually did CT begrudgingly.

    So CT showed an appy. of course. Impressive stranding, no rupture.

    I honestly send these folks home most of the time. I don't know why not this time.

    The part that pissed me off was the griping from the surgeon of why the CT? Pretty much just being a [email protected] thistle. They have no idea the thought process that goes in and the back and fourth about diagnostics in such cases.

    So I told him that I would simply call him at 0200 for every RLQ pain in a young male regardless of exam and he can figure it out.
    Does he come to the ER to confront me? Of course not.

    Lesson for young EM folks. Often, there are just no win situations.
    Nurses were like, "great catch!"
    I said, "not really."
     
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  3. MSmentor018

    MSmentor018 Hooah! SDN Advisor 7+ Year Member

    I am sure you've seen appys of all presentations. every year i get 4-5 the "tip of the appendix is inflamed" so the pain could be ruq, rlq, suprapubic, right flank, right cva area pain. had a buff weight lifter coming from the gym saying his epigastric area felt like he did 100 sit ups but he only did half that. was eating and watching tv. yep. appy.
    if they're under 18 we have a kub, u/s, ua and labs protocol then transfer to the surgeon. above 18 do whatever. I've had some pts from missed ruputred appy with multiple complications, fistulas, adhesions...etc and when I asked what happened, they openly said they sued and won. the liability is too great for a "routine" dx. just scan'em bro
     
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  4. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Indeed!
    And our shop's US utility for these is abysmal this guy was too big too.

    The only point I think I have from this for young docs is that sometimes there is simply no winning.
    Sometimes consults will be complete idiots on the phone despite you going through a rather thoughtful process.
    I was really, looking forward to hearing his grievances in person. Oh well.
     
  5. e30ftw

    e30ftw peace 5+ Year Member

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    I feel like the majority of 18-25 y/o w/ appendicitis I see have normal VS, are tolerating PO, have a normal WBC, and the only exam finding is that they slightly wince when you deeply palpate the right lower quadrant.

    The only reason the surgeon was upset is because you woke him up. If he didn't want to be called about appys in the middle of the night he shouldn't take call.
     
  6. shoal007

    shoal007 2+ Year Member

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    same thing happened to me. 34 yo m with diffuse abdominal pain x 2 days - tried gas x and laxatives without improvement. stoic guy, moms a nurse worried about an appy. barely tender on exam. nml wbc, ua. impressive positive CT. surgeon throws a fit and of course takes him the the OR the following day anyways. You cannot always win, but gesalt gets you far and you're unforunately much better scanning than not.

    Sent from my Pixel using Tapatalk
     
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  7. carbonizedeyesockets

    carbonizedeyesockets 2+ Year Member

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    One of my attending caught a stump appendicitis at our community site. Glad to know that I can't even count on prior appendectomy to 100% rule out appendicitis.
     
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  8. WildcatS11

    WildcatS11 7+ Year Member

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    Caveat - im only 2.5 years into residency - but i haven't seen anyone go to the OR for r/o appy without a CT. Maybe that's a product of an academic environment, but even at our community sites it doesn't happen. Maybe we are more liberal with our a/p scans? Maybe our surgeons are more hesitant? I'm not sure.
     
  9. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    Yep, with appendicitis you're always either calling too early or calling too late. Pick your poison and take a gulp.
     
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  10. MSmentor018

    MSmentor018 Hooah! SDN Advisor 7+ Year Member

    you could invite them to stop by afterwards and say thank you but I doubt they'll want to
     
  11. erdoc00

    erdoc00 2+ Year Member

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    My personal favorite was "I've had this pain for 4 years intermittently...it always seems to get worse around this time of year".. early 20s male, happy and smiling, rlq pain was his complaint. Exam soft not really tender, but "oh yea I think that's where it hurts most" when I press at rlq. WBC 11...

    CT shows acute appy

    I've stopped trying to make sense of it.
     
  12. filhodeinferno

    filhodeinferno 7+ Year Member

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    I've had the same experience. Never seen appy go to OR without a scan.
     
  13. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    I've said this before on SDN - around 10 years ago, there was an older (but not "old", per se) surgeon who I called to lay hands on the pt without a CT. He took the pt to the OR without a scan, for clinical appendicitis. And, believe it or don't, that's what the pt had!
     
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  14. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization 10+ Year Member

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    I've had a lot of these experiences where "but for the grace of God, there go I." Maybe a 2nd trop on a flakey story comes back positive. Appy when you didn't expect it. FB in a laceration with no FB sensation. PE in someone you thought had chest wall pain but they weren't quite PERC negative. Makes you a bit paranoid and more likely to test for sure.

    But the key is to sit down with the patient and their family and have the talk. Talk about the possibility that this could be appendicitis. Talk about coming back in 12 hours for a repeat exam. Talk about the fact that doctors don't know everything and our tests aren't perfect. If nothing else, you'll figure out what kind of a patient they are. Some patients NEED that CT on THIS VISIT. For other patients, it's the wrong move. They fear the radiation more than the delay in diagnosis and the 2nd co-pay.

    Some patients want to be admitted. Others do not. If both options are safe and reasonable, I let them do what they want. That happens a fair amount of the time.

    But you've got to figure out a way for your practice to not be so busy that you can't have these conversations. They're critical to the effective, safe, and cost-efficient practice of EM.
     
  15. shoal007

    shoal007 2+ Year Member

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    wow very insightful and well said. guess that's why your website has such a following.

    thank you.

    Sent from my Pixel using Tapatalk
     
  16. GonnaBeADoc2222

    GonnaBeADoc2222 7+ Year Member

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    Similar appy story, only this one was post-op. Was during my first outside moonlighting shift during residency in a free standing ED.

    Late teens kid with very mild RLQ pain/tenderness ~10 days s/p lap appy (ruptured). Chilling and reading on stretcher. Afebrile. No vomiting. WBC 11.

    Something tickled the spider sense...I was for some reason bothered by the fact that he had persistent mild pain despite his post-op status. Also with ever so mild leukocytosis.

    Really mulled it over because I supposed u/s would be useless in this situation and the patient had a CT the first time around to dx the thing in the first place. So repeat diagnostics would cost this kid 2 CTs in 2 weeks.

    Pulled trigger on CT...something like 5x5 cm focal abscess...transferred to mothership...got IR drain.

    Not totally weird...but I could have easily sent home...with strict return precautions of course...
     
  17. docbooboo

    docbooboo New Member 10+ Year Member

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    Midlevel saw 10yo male for upper abd pain after bicycle accident. Ordered CT rule out liv/spleen lac. CT comes back as acute appendicitis.

    Sent from my SM-G930P using SDN mobile
     
  18. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    Any possibility there may be overreads by radiology here? I know we're not radiologists, and it's not really our job, but sometimes I wonder...


    Sent from my iPhone using Tapatalk
     
  19. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    Yes
     
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  20. TraumaLlamaMD

    TraumaLlamaMD Licensed to chill 2+ Year Member

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    Depending on the usefulness and availability of your US techs, it's feasible to start here. I've seen more than a few post rupture appy kids come back with RLQ pain and US shows a loculated fluid collection - off to IR they go, who can often place the drain under US guidance too.
     
  21. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    I've seen it about a dozen times. All at a children's hospital though.
     
  22. JustPlainBill

    JustPlainBill Attending 10+ Year Member

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    Same-same at Parkland. Had a surgery resident tell me to get real imaging on a patient ttp over mcburneys with lekocytosis and febrile--US showed appy....CT came back positive....he was a bit of a schmuck so we had an interesting conversation....
     
  23. Hamhock

    Hamhock 7+ Year Member

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    I'm convinced the natural history of some appendicitis includes spontaneous resolution. It must.
    When I remember this, hearing about CT appendicitis without clinical appendicitis scares me much less.
    HH
     
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  24. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    Appendicitis is a simply a specific kind of diverticulitis.
    Treating it with antibiotics works a lot like surgery except for the recurrence rate.
     
  25. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    I don't particularly worry about missing it. If I'm not going to scan and D/C I document my benign abdominal exam, negative labs, and 12 hour close follow-up in the ED.
     
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  26. ensuii

    ensuii 10+ Year Member

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    Environment has a lot to do with it to. I can't see you being liable for missing anything in Texas if you do this and they bounce back with a ruptured appy. Other places however...

    I work in a decently busy community gig where metrics are important. For me, almost every RLQ abd pain gets labs, ct and a dispo 60mins later. I can't really see myself calling a surgeon without a CT.
     
  27. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Indeed. Partner in my last group was sued for missed appy with wonderful documentation. It was solid! Labs were normal and even did a CrP:/
    Kid went to another ED ruptured and had complicated surgery.
    In some states, bad outcome = someone pays, regardless. Ended up settling but really negatively impacted him! Process took years and he was never the same.
     
  28. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    Forgive me, what's a CrP:/
     
  29. WildcatS11

    WildcatS11 7+ Year Member

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    Assuming c reactive protein...
     
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  30. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    Ahhhhkay. Thanks. Sorry for being dense.
     
  31. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Yes..sorry for the thumb type weirdness
     
  32. ballinsncbirth

    ballinsncbirth Junior Member 10+ Year Member

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    See i really dont understand this thought process....

    male adult pt with RLQ pain .....STOP ...GO TO CT SCAN .... NEXT PATIENT .

    Why would you even think to not CT scan this kid? you spent hours observing him with repeat exams .,.. 15-30 minutes to sit there a discuss all the options with mom ... and sat there going back and forth in your head ?
    for what ? to save a 19 year old some mild radiation? and guess what YOU STILL CAN GET SUED FOR NOT GETTING THE SCAN no matter how great you charted, or how nice you were.

    CT SCAN NEXT PATIENT. ....

    i mean you even charted RLQ tenderness ? why would you think you would send that guy home without some radiation? You literally just wrote a note supporting your law suit.... Noone should ever go home with a chart that says the word tenderness on it without some imaging.

    I could care less whether there is a surgical abdomen , or what my exam shows..( AS A RULE OUT MECHANISM ) guy mentions the word right lower quadrant (especially in the triage note) he gets scan ...


    Also i dont understand why would you think of calling a surgeon? when you have a ct scanner available ... I can understand maybe a small kid with an obvious exam or if you in alaska somewhere without a ct scanner, or maybe at the academic center when a surgeon and their team is in house 24/7 . Would you really want to take a patient to surgery without a ct scan this day an age? Why, as a surgeon would i come in from home to do an operation without a ct scan ? you can get the scan done way before the surgeon even shows up .

    how many times has an acute abdomen turned into gas, or constipation etc. The risk of ct radiation is WAY less than the risk of unnecessary surgery ,and even if positive the ct scan can show valuable information ie Rupture/free air/abscess.

    just do the scan a move on bro
     
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  33. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    "Just do the scan and move on bro" is pretty much my line of reasoning, too. Given the myriad presentations of appies (appys?) and the risks involved - just do the scan.
     
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  34. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    Dude, your average patient age is 99. If I worked there, I'd order the first 8 labs that popped into my head, CT WHOLE BODY, and call the admitting service when the patient hits the door. /Sort of sarcasm
     
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  35. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    Yeah, you're not wrong. Lol.

    It's high snowbird season, too. I went to go hit some golf balls today at the range, took a look around, said something in my head like: "Look, there's the fossilized remains of golfers from the Northeast." Went to my local pub, looked around... Nothing but cotton candy haircuts and glasses of white zin. I feel so out of place in general, but nobody bothers me, so I take the good with the bad.
     
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  36. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    I find that to be...petrifying.

    (Sorry, buddy, had to do it!)
     
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  37. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Sorry, but you can practice this way... I just don't.
    I did for a short while and hated myself for it.
    Hey, but to each his/her own!

    This is not a pt I would have scanned.
    And part of the reasoning here was to illustrate that aspect of it.
    Would I be perfect if I scanned based on CC? Nope. CTs can be negative early on too.

    I do not scan RLQ for the sake of it being RLQ pain.
    The practice of doing this pretty much negates our need for being there. Common!!

    Does it happen all the time? Sure does. I do not subscribe. Sorry.

    Does this make me non productive? Well, I still rank high in productivity and decompress the WR with the best of them. So, no.
    But I was never the guy that could be happy with just moving meat.
    I have found it really no big deal at all to be productive and still take my time and give my 100% to each case.
    When I was at a sweatshop seeing 3pph, this was not possible.
     
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  38. ballinsncbirth

    ballinsncbirth Junior Member 10+ Year Member

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    I am not telling you to scan every patient. I actually utilize CT scanning less than most... But I do suggest scanning the obvious appendicitis.

    by your own admission this guy has rlq, pain , rlq tenderness of exam , in a 19 year old male? that to me is quite obvious appendicitis until proven otherwise.

    They do not need to have rebound, guarding , rovsing or all the other ridiculous exams people used before the advent of ct scanning. You can keep talking yourself out of scanning these guys and believe me you will miss many appys .


    You send this guy home charting RLQ tenderness, and rlq pain , and this guy comes back with perfed appendicitis you are BURNED . Why would you chart the guy is tender in the rlq ? that literally a lawyers wet dream of a case.

    I reckon 99% of docs would scan a guy like this.

    and you are right ER docs are not there to catch this case... this is a pretty cut and dry case. WE are there to catch the guy with LLQ pain or RUQ pain, or uti , or vaginal discharge, that have appendicitis. These are the cases in which are skills come into play . This guy is screaming appy .

    We know appendicitis is difficult to diagnose, we know labs are useless, we know rebound guarding is not worth anything in RULING OUT appy . The hard cases are the ones coming in with generalized pain , LLQ pain , chest pain , fever, UTI that have appy.

    and if you are going to send a guy like this home you better make sure the chart is PRISTINE. No tenderness, no abdominal pain , especially no RLQ pain .

    Its not about being productive , or moving the meat, it is about understanding the medicolegal environment you are in

    BEST advice I ever got from an attending was
    There are only two reason to chart , 1: billing 2: defend yourself in court

    You are in control of what goes into a chart. Don't ever put anything that would be used against you in court. Don't do the prosecutors job for them .
     
  39. AlmostAnMD

    AlmostAnMD 2+ Year Member

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    I have a fantasy about opening an ER where to get in from the non-ambulance bay you have to get a full-body CT and then register your chief complaint. Then the radiologist looks at the area of interest related to the CC and by the time you're called back I already have your CT results

    President Trump only cares about efficiency, not radiation, maybe I'll get to try this out. Gotta keep up that PPH
     
  40. exi

    exi 10+ Year Member

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    Just curious -- what state was this?
     
  41. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    There is a third reason to chart - so the other docs can read it and see what happened on the patients prior visits - that's helpful in sniffing out trolls vs legit stuff


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  42. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Illinois.
     
  43. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    I am well aware of the medico legal environment.
    Perhaps I just walk a fine line. I will say though my current group sends home a fair amount of folks with scheduled return visits.

    Is it full proof? Of course not. As I mentioned before I was in a group that had a partner with a terrible case that was DCd home.

    Is it the right thing to do for the PT at times? Absolutely.

    That's why I spend a lot of time on these.
    My charting is over the top on every case, that's just how I was trained.
    I have not been a part of any legal case as of yet (knock on wood) and in a bit over 10 years I imagine I have seen a couple of abdominal pain cases;)
    I scan the very young only very rarely, but still have scanned more than I can possibly remember in my career.

    And I disagree with it not being about moving the meat. We all know that is a main driver. I am not saying it is for you, but it certainly is overall.
     
  44. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    You may be in control of what goes into the chart but if the chart is obviously contraindicated by objective facts or contemporary eye witness testimony then lying on it isn't going to save you. There are plenty of areas were resolved RLQ tenderness with nl labs and no CT scan and early appy precaution d/c instructions could be considered standard of care. Let's take it to the extreme. Would you refuse to document pt had chest pain if you weren't going to admit them?

    As far as attending advice, "No, it goes in the other hole".
     
  45. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    I hope that advice was airway related.
     
  46. bravotwozero

    bravotwozero Chronically ambitious 10+ Year Member

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    Probably wasn't


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  47. ballinsncbirth

    ballinsncbirth Junior Member 10+ Year Member

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    well obviously don't contradict anything. But that is kinda my point. If i am discharging a chest pain I sure am not going to chart exertional chest pain radiating to left arm with numbness , shortness of breath ,nausea and a "elephant on my chest. If by my clinical evaluation he has non cardiac chest pain , charting "typical" sx and then discharging is not smart. Who is going to be able to contradict YOUR EXAM ? (and if there are obvious contradictions in the history ie nursing notes , CCC then be sure to resolve them )


    I do not chart anything the does not support my disposition. especially high risk cases. I am not advocating lying on the chart. but why chart tenderness in the rlq , of a pt presenting with rlq pain that you are sending home without a scan ? It can only hurt you and not help. Why chart something that would hurt you in court? You have made your clinical decision regardless of what the chart says , make your chart as defensible as possible.

    don't put nails in your own coffin ...

    no one is going to care what you charted if that pt goes home gets better on there own with no complications. The only time you will ever care about you chart is for billing , and defending yourself in a court of law and /or hospital committee etc.

    Always chart as if the pt will come back dead the very next day.
     
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  48. julie29524

    julie29524 Member 10+ Year Member

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    During the 1st month that I was an attending in a community ED, 2 yo M presents with vomiting for 1 day, well appearing, afebrile, vomited once in ED, abdominal exam non-focal, difficult due to age, but no peritoneal signs, but not crying during abd exam. My suspicion was pretty low, but since I was fresh out, did an US, radiologist read as normal. A week later, my medical director told me that a pediatric surgeon called him 5 days after that visit, to complain about me that pt had a ruptured appy when they went to another hospital 5 days later, the normal US I ordered saved me.

    I've also had the "abd pain for 5 month, CT show appendicitis" patients.
     
  49. GeneralVeers

    GeneralVeers Globus Hystericus 10+ Year Member

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    That is the problem with pediatric appendicitis. Under 4 years old and will almost certainly be a missed diagnosis. There is no way around it. Only way to catch it would be CT on every young kid with a fever.
     
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  50. Birdstrike

    Birdstrike 5+ Year Member

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    Any catch is a good catch. And why are you beating yourself up over this?
    I sense shift-work sleep-disorder (which I have powerful radar for, as a sufferer, in remission).
    Order tests. Diagnose people. Treat people when you have something treatable. After all, you are a doctor, not an accountant, a lawyer, a politician or and administrator.

    It was a good catch.
     
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  51. TrumpetDoc

    TrumpetDoc 7+ Year Member

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    Thanks man!
    I suppose it was more an issue with the surgeon's response, coupled with an end to a 5 night string (perfect storm)
     
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