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Tag Archives: Patient Encounters

Proving a Negative

A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem. Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms. The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier. No old records in the computer. I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any. I asked her to show me her drivers license. Nope. Didn’t have that, either. I was quickly developing an opinion that this was a snipe hunt. Snipe hunts like this are an example of another conundrum that many physicians face. We are often expected to prove a negative. Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible – don’t comment with all your weight loss feats] that any patient could lose 50 pounds in a month. But what if …? What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for? What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities? Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem. I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready. A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups? And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation. I’m going to be eating my words if she comes back next month weighing 80 pounds.

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Time for a New Roommate

Second time in a week. The first episode, the patient from the assisted living facility came in with sharp anterior chest pain. She said that she was sleeping and woke up with sudden onset of pain. When she opened her eyes, her roommate was standing over her with a crazed look in her eye. Sticking out of her right breast was a ball point pen. Fortunately, the injury was to adipose tissue only and didn’t require any surgical intervention. On her most recent visit, the same patient returned after waking to her roommate’s friend beating her with a cane. She tried to fend off her attacker and fell to the floor where the friend repeatedly pounded her in the stomach with said cane. She had a lip laceration and multiple bruises to her abdomen. I feel so bad for this patient because she’s doing nothing wrong and getting beaten in her sleep. It’s not like a loan shark is trying to collect on a debt or anything like that. Definitely time to find a new roommate. Or a new facility. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Unnecessary Testing?

A patient was sent to the emergency department to have an ultrasound of her uterus performed. She had been having abnormal bleeding which coincided with about the time her period was due – only it was a little heavier and lasted a little longer than usual. She decided the best course of action would be to make an emergency appointment with the gynecologist. She was seen the day before she was sent to the ED and the gynecologist performed an ultrasound in his office … which was normal. The patient called the gynecologist the following day and said that the bleeding was still there, so the gynecologist told her to go to the emergency department for another ultrasound and some blood testing. The patient arrived stating “I’m here for my ultrasound. Dr. Speculum sent me.” Since patients need orders for testing to be performed, the patient was given the choice of waiting to be seen in the ED or of getting a prescription from her doctor for the exam. She chose the former. After examining her, we performed a pregnancy test which was negative and a CBC which was normal. So I told the patient she was likely just having a heavy period and that she could follow up with her gynecologist as an outpatient. The patient demanded an ultrasound. After all, Dr. Speculum sent her to the ED specifically to have an ultrasound done. So I called Dr. Speculum. “Hey, it’s WhiteCoat here. Your patient is here with metrorrhagia and I’m trying to discharge her, but she insists that you want her pelvic ultrasound repeated.” “Yeah. Can you do it?” “Well what are we doing it to look for?” “Fibroids” “OK, well if she does have fibroids, are you going to admit her? Her hemoglobin is fine.” “Noooooo. Discharge her after the ultrasound.” “So then why … nevermind. If all you’re looking for is fibroids, weren’t you able to see that she didn’t have any fibroids on the ultrasound you did on her in the office yesterday?” He must have really wanted that ultrasound by his response. “Naaaaaaah. The ultrasounds I do in my office aren’t accurate.” Allrightey, then. The repeat ultrasound was still normal. I guess he was more accurate than he gave himself credit for. Wonder if she’ll be referred back to the ED tomorrow for repeat pregnancy testing. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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I Made A Drug Seeker Cry Today

I made a chronic back pain patient who was out of his pain medications cry in my emergency department today. Actually, he was already crying when he came in. The nurse said that he hobbled in from the waiting room bent over like an old man and using his wife’s shoulder for support. He couldn’t stand upright because of his severe pain. I was finishing up with the patient in the room next to his when I heard him get put into the room. He was moaning and moaning. As I discussed the discharge instructions with the current patient, the moans sometimes overshadowed what I was saying. Before going to see the patient, I looked up his old records on the computer. He was 41 years old. According to his old chart, he had wrenched his back while fixing the tire on his car more than a month ago. Ever since then, he had been having pain in his lower back. His primary care physician gave him a couple of weeks of Percocets and some Valium. Those medications helped him somewhat, but he still had pain. When he ran out of the meds, he got one week’s refill and was referred to physical therapy. He went to physical therapy twice and it caused the pain to get so bad that he stopped going. He called his doctor back and his doctor ordered MRI of his back. I pulled the MRI report which showed multiple minor disk bulges but no other problems – definitely nothing that would cause his back pain. So his doctor set him up with a pain clinic. No appointments were available for more than a week and his doctor had cut him off from narcotic pain medications after the relatively normal MRI. This was his third ED visit in the week. When I walked in the room, he was in a fetal position on the bed and he was crying. “I’m Doctor WhiteCoat. How can I help you today?” “My back, doc. It’s killing me.” He described the whole story. I already knew most of it from notes in the computer. I also saw the several doctors from whom he had received pain medications. He wouldn’t lay flat on the bed because he said it made his back worse. His position of comfort was laying in a fetal position or laying on his back with his knees flexed. Back in medical school, I worked part time in a back pain clinic for a year or so (long story). After a normal neurologic exam, I thought he probably had a psoas muscle spasm. Pretty common cause of non-traumatic back pain. So I gave him some Toradol and Valium. I told him that I thought I knew what was causing his pain and that if he trusted me, I could probably make him feel better. Fortunately, the ED wasn’t too busy that day, so I could spend a little extra time with him. I got him to lay on his back with his legs flat. I went to see another patient. I came back and had him roll on his stomach. I went to see another patient. I came back and used the stretcher to extend his back a little. I went to see another patient. I came back and used the stretcher to extend his back a little more. He moaned in pain. I went to see another patient. After the third incremental extension, I let the bed back down. I showed him how to get out of a bed without putting a strain on his back. Then ...

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WTF Moment #1071

What is it with some people and rashes? The patient waits 3 hours to be seen. When I enter the room, the patient says “I had a rash on the back of my leg 2 months ago. Can you tell me what it was?” Out of the 4 or 5 things running through my mind at that point, the least pressing one of them wasn’t about calling up the feds to get satellite video feeds of the patient’s house two months ago so I could zoom in through the window shots and hopefully identify the cause of the mysterious rash. “The rash isn’t there now?” “No.” “Well, sir, I honestly don’t know what caused the rash because I can’t see it any more. As long as it isn’t there any more, I don’t think it’s going to be a problem.” “Was it scabies?” “I doubt it because it wouldn’t have just gotten better.” “Well what does scabies look like?” At this point, I should have stopped the conversation and discharged the patient. Unfortunately, my foresight gene had gone offline for a few moments. “Scabies is usually little itchy spots or pus-filled blisters. Most commonly the spots are between the fingers or the toes. Sometimes there will be little red lines where they burrow under your skin.” “Wait. You mean scabies are bugs?” “They are mites.” “Oh my God. That’s what the rash looked like. I’ve got bugs burrowing in my skin.” “No. You don’t. The rash is gone.” “What if they’re just sleeping? Couldn’t they still be in my house?” “I’ll tell you what. If the rash comes back and you think it is scabies, there’s cream called elimite that you can buy over the counter to kill the mites. Until then, I wouldn’t worry too much about it.” An hour after he was discharged, we start getting the phone calls. “My son said you told him my house was infested with bugs. What’s THAT all about?” “How long should he stay home from school for?” “Can these bugs be sexually transmitted?” “Should I be going to work? I work in a nursing home.” [facepalm] My shift couldn’t end soon enough. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Useless Workups

A patient calls his family doctor and gives a history of having chest pain on and off for the past few days. Pain worse with activity. Not having any now. Of course, you know that the family doc is going to send the patient to the Emergency Department. You just know it. So the patient gets to the emergency department and of course the EKG is normal … and the labs are normal … and the chest x-ray is normal. Because the patient has no history of chest pain workups, of course you know we have to recommend that the patient stay overnight and have a stress test in the morning. “You’re kidding. I really have to stay? Everything is normal. Can’t I just go home and do it later? ” “Well … no … not really. We can’t force you to stay in the hospital, but we really think that it would be a good idea.” Then you start to second guess yourself. This guy’s in good health. He’s not having pain now. Of course the insurance company is going to call this an unnecessary admit. Fortunately for everyone, you found a reason to justify the admission. About 15 minutes later, the alarm goes off. Holy sh**! Torsades! Get the paddles! It seemed like several minutes, but it ended up being more like 35 seconds until this happened. “What happened?” “Um. You nearly died.” Had the patient not called his doctor, had the doctor not sent the patient to the hospital, had the patient not been brought right back and place on a monitor, or had the patient decided to leave AMA, he probably wouldn’t be here right now. Triple vessel disease with a CABG. Every once in a while those useless workups end up saving a life. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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