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Patient Encounters

Reasonable Conclusion?

When, over the period of 10 minutes, medical personnel hear the following statements from an elderly patient: 1. “You come any closer to me, I’m going to stick my boot up your a** so far, I’ll come out with a bare foot,” 2. “Up your a** with a meat cleaver,” and 3. [While making sure that the patient has a steady gait] “Stop following me. Next thing I know, you’ll be sticking something in my a**,” is it reasonable to conclude that the patient has not passed the Second Stage in Freud’s Psychosexual Development Model? This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Didn't See That One Coming …

When a young male patient has a urinary tract infection and difficulty urinating, usually a check for prostatitis is in order. Add prostate checks to the list of things where you can “expect it.” When checking a patient for prostatitis, I will usually say something to the patient along the lines of “When I press here [while pressing on the prostate] does it cause you to have more pain?” Most of the time, patients are already screaming. “Yeah, it hurts like hell. You done yet?” -or- “Owwwwwwwwww. Daaaaaaamn. Owwwwwwwwwww.” Really want to skeeve your doctor out a little? When he asks you if pressing on your prostate hurts, tell him “Actually, it feels kinda good.” [shudder] I’m considering empirical treatment for prostatitis from this day forward. This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.    

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Miscellaneous Pain Histories

Had several notable histories from patients in pain lately. One patient with chronic back pain hobbled into a room and said “I better not be waiting here 8 hours like I did last time.” We looked through her old chart out of curiosity to find out what caused the extended eight hour wait on her previous visit. The longest that she had waited in her prior seven visits before getting her shot of Dilaudid so she could go home and sleep was 2 hours and 15 minutes. Of course, making comments like that to the staff has no effect on anyone’s passive-aggressive behavior. Really, it doesn’t. Another patient with chronic back pain had an acute exacerbation and needed pain medication. When he took off his coat, he was wearing a T-shirt that had a logo on the back. At the top was “Stoner Steve’s.” Underneath was a big circle with a line through it. Inside the circle was written “Motrin, Klonopin, Ultram”. The line through the circle was a marijuana joint. Why in this world Stoner Steve decided to advertise his aversion to these three specific medications is beyond me. Of course, wearing a shirt like that to a hospital emergency department and asking for pain medication has no effect on the doctor’s tendency to prescribe you Motrin, Klonopin, and Ultram. Really, it doesn’t. Finally, there was a patient with a chronic toothache. He tried taking some Vicodin that he had in a cabinet, but it didn’t taste right and, more importantly, it didn’t work. Then he looked at the bottle and it was a year out of date. And he stored the bottle above his refrigerator, so the heat probably degraded the medication even more. So he dumped the rest of the bottle into the toilet and flushed them. He needs another prescription to replace those pills. And he didn’t bring the bottle, either. He threw that out. First of all, medications don’t all turn into arsenic the millisecond after their expiration date. Few medications lose much potency after expiration, either. See WSJ article here (full text here). More importantly, most states have a database that tracks when patients fill prescriptions for controlled substances. Presenting with a history like this doesn’t affect the tendency for a doctor to look up your name on the state database. Really, it doesn’t. It does make things a little uncomfortable when a patient hasn’t filled an opiate prescription for more than a year and I show them a printout that they have filled five opiate prescriptions from different doctors in the past month. What? Wait. Where are you going? Why are you leaving? I was going to write you a prescription for Motrin … or Klonopin. This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Revenge Best Served with Hot Lead

A young guy gets brought in with a non-life-threatening gunshot wound to his arm. The police were called and the patient had no idea who shot him. After the police left, the patient admitted that his own friend shot him. He was sent home that night. Not 45 minutes after my shift started the next day, the patient’s “friend” comes in with a GSW to the leg. Guess who the perp was. Can’t you just smell Jack Daniels and hear someone yelling “How do YOU like it” in the background?   This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Meet Babs Bunny

A dad brought his 15 year old daughter in because she had missed her menstrual period the past week. He kept her home from school for three days because he wanted to see if the period had just decided to show up late. Alas, after 5 extra days, no period was forthcoming. The young girl’s pregnancy test was …. positive. When the nurse told the father that his daughter was pregnant, he wigged out. “You mean she’s having a baby NOW!?!?” No, sir, the gestation in humans is 9 months not 35 days. You’re thinking of rabbits. This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.  

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Diagnostic conundrum

A man in his 5os drives himself to the emergency department with 10/10 crushing chest pain, nausea, and shortness of breath. He was clearly uncomfortable when he arrived. Why did he drive himself there? Well, he was going to call an ambulance, but he happened to be only a couple of blocks from the hospital and thought driving would be quicker. Heart attack, right? Well, the EKG showed LVH with minor repolarization abnormalities and the POC troponin was negative. No acute MI. The patient got some nitroglycerin. The chest pain didn’t improve, but the patient became hypotensive. He got IV fluids. ECHO tech comes in and does an ECHO. No wall motion abnormalities. Normal ejection fraction. Mild LVH. An essentially normal exam. Labs returned and CBC and chem panel are normal. D dimer is significantly elevated. His blood pressure comes up so he gets IV morphine. Pulmonary embolus, right? Well, the CT scan showed no PE. And there wasn’t a dissection, either. But the CT scan did show some abnormality coming off the aorta that wasn’t present on ECHO. Different density than blood, so it wasn’t a dissection. We decided to admit the patient and do further testing. Not so fast. The patient has an HMO and our hospital isn’t in network. His chest pain is better after receiving the medications, so he gets transferred 30 miles away to another hospital. What was his final diagnosis? We don’t know. Never got a follow up call. That’s one of the downsides to emergency medicine. You don’t get to finalize workups as often as you’d like. Was it esophageal spasms, a cardiac tumor, or a sneaky circumflex lesion? Most of the time you don’t get follow up until one of your colleagues comes up to you and says … “Hey, remember that guy with the chest pain you saw last week?” And you think to yourself “why didn’t I become a plumber?” This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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