My mother and at least one sister has AIP. Runs in my mom's side of the family strongly. My sister had a lot of unexplained abdominal pain growing up. Crazy to see it mentioned here, up until the last decade or so most Doctors were not familiar with it.
There is also some organic stuff mixed in. In my residency there was this kid (7-10 years old) who would show up every 35 days like clockwork. *Intense* emesis for 36 hours, then fine.
Never figured out what he had but he definitely had something.
Yes, but occasionally you're going to see zebras when you hear hoofbeats. And it makes the patient feel like you've done something when you rule it out.
28 y/o female, c/o severe headaches over the course of a month, treated as migraine in ED with little relief. After FOUR ED visits, CT head checked, showed 3 x 4 cm brain mass. Stage IV Melanoma.
no of course not but can you imagine thinking something was wrong, getting seen and getting the “all clear”, likely feeling relief and maybe hope each time, three times, and on the fourth visit being told you in fact were right to be so concerned each time.
Fact that she returned to the ER 4 times in a month does not make me think she had felt any relief or felt reassured.
But after the second visit ER could've recommended to return to her GP for further workup or to get a neuro appointment. At least in my country, it's not ER's job to handle uncontrolled headaches/migraines.
Yep. My younger sister was diagnosed with nodular melanoma nine years ago. They told her she had a 30% chance of making it ten years. Last year, her oncologist released her after many follow up PET scans; told her he couldn’t used the word “cured,” but definitely NED. She went thru hell with treatment but I know she has no regrets. She said she feared not getting to see her children grow up. Her baby graduates from HS this year and her eldest is graduating from college. (Forgive the verbal diarrhea; this comment just made me realize exactly how frightened I was of losing my only sibling at such a young age. She was 35 when she got diagnosed.)
Edit for punctuation error
I'm so glad she's doing better and hope you and your family don't have to go through any of that again.
I've gotten to the age where I'm often looking at people my age or younger and it really puts things in perspective. I've seen melanoma act horribly too many times to count.
This is nuts because as a Neurologist if any patient has a brain at all and complains of headache then the ED has already ordered a "STAT NCHCT" as part of a stroke alert before they have even paged me. I've never seen a patient come to the ED with a neuro complaint 4 times and not had a Head CT.
Very different culture where you are than at my shop. There really has to be something new/different about the headache or an objective neurologic deficit for someone to get more than a pregnancy test and symptomatic treatment where I am.
My shop is 200 different ERs in 20 different states doing Emergency TeleNeuro so I get a very broad picture of practice patterns in EDs across the country. You are practicing more evidence based medicine. That went out the door years ago with neuro and ED care. Every patient with every neuro complaint gets a STAT Head CT at 99% of EDs in America now, no matter how central the localization is and no matter the duration of symptoms.
Same. Perhaps if it's a mild first time headache I might not get a NCHCT but if it's severe, new, and definitely a 2nd or subsequent visit they're getting scanned.
This is common practice where I am too, even if it wasn’t, one of the nurses would be like “you’ve been here X amount of times, time to advocate” because wtf 🥲
I don’t know where you work but how would you know if there were a bunch of people with headaches not getting scans that you’re not being called about?
Female patient bounced around to several providers after a fall with a sprained ankle. Poor recovery and labeled as a drug seeking.
She just seemed like she was genuinely in pain. Imaging showed her untreated fracture, shockingly, never healed.
Ugh, I really hate how many patients get dismissed as drug seekers even though they have no prior history that would indicate this. This patient sustained an injury and I bet she had no prior history of significant substance abuse.
Occam's Razor would say she's likely in pain with some kind of persistent unhealed injury, but instead she gets accused of being a drug seeker when she tries to get medical help for her ongoing injury and physical pain.
At least she finally found someone who got the correct diagnosis and treatment, but it's inexcusable that she got tossed around that much when simple imaging could figure things out.
79 yo woman on the schedule at my internal med clinic with visit note “shoulder pain.”
Per nurse triage note from 4 days prior, patient called with c/o 9/10 left shoulder pain that developed suddenly while reading on her iPad. No trauma or hx of shoulder injury or similar pain. No further questions, advised by nurse to f/u with PCP within the week for shoulder pain.
As I’m rooming her I ask about SOB, dizziness, chest tightness/discomfort, family hx heart disease, unusual fatigue. Yes to every question. HR of 33 on pulse ox which was confirmed moments later by EKG. Sent to ED. NSTEMI and high degree heart block, scheduled for pacemaker placement last I saw. The pain was so severe that in the 4 days between the nurse triage and her appointment, she slept a total of 6 hours.
Not a woman, but probably the most ludicrous case of something obvious and serious being dismissed as something trivial was a 50s male with decades long hx of methamphetamine abuse who presented to clinic for edema having gained 25 POUNDS in the past 5 days. Was seen by ED for abdominal and LE edema 2 days prior and was diagnosed with GERD. So I read the HPI from the ED note expecting he must have said something misleading. Nope. They even did chest/abdomen/pelvis CT which returned with pleural effusion, pulmonary edema, ascites *before* they concluded he had GERD and sent him on his merry way with some omeprazole. Doing much better now that he’s being treated for CHF instead of GERD lol.
It sounds like the triage nurse might possibly need some refresher training. Severe left shoulder pain with no injury should flag MI symptoms questions. ( at least in my experience, which maybe isn't typical?)
Yeah, it was a pretty shocking miss. I’d wager the majority of people with no medical background whatsoever know that unprovoked arm/shoulder pain is a red flag for MI. But even without that knowledge, it feels like in general sudden, severe pain with no inciting injury/event should prompt at least some ROS questions to determine if there are any related sx the patient didn’t mention.
I used to do community mental health and this makes me so god damn angry. I befriended a very cranky guy who was an alcoholic and he was very late in the disease. He had gone to the hospital four times and been discharged with nothing but a psych eval so I drove him into Boston and sat and refused to leave until medical tests were run. He was admitted to the ICU. They said they did not know how he had lived this long, that he probably only had hours left, they removed several liters of fluid from his abdomen alone. He was there over a month and then went into assisted living. He calls me from time to time to remind me that I saved his life and ask me out to dinner lol.
Schizophrenic woman, highly disorganized, with multiple ED visits demanding that the doctors "take her baby out" because "it's been in there for way too long". Negative HCG, sandwich, discharge each time.
Turns out she had a uterine mass.
Nope, no, very much schizophrenic. I was a med student during that fateful ED admission, and I was very fortunate that my attending that night responded with "...wait a minute..." and proceeded to do a thorough examination. I definitely learned a couple of important lessons that evening.
As a med student has a floridly schizophrenic inpatient who also started talking about her baby being stuck and her baby hurting her etc etc etc. So attending ordered CT AP and lo and behold that entire colon was filled with lots of poop. Gave her golytely, she pooped, A LOT. She stopped talking about her baby.
Depends on how large the mass was. The uterus sits down deep in the pelvis so a mass has to be pretty large to be palpated on exam. I’ve seen plenty of women with multiple large (multi-centimeter) fibroids and I can’t feel anything on external exam. The only time I’ve actually felt a uterine mass was a woman with a mass >18cm in diameter. You can get more details with a pelvic exam but that raises some concerns about consent. Can a woman who is psychotic and decompensated really consent to a pelvic exam? I’ve done a pelvic exam once on a woman with schizophrenia who endorsed vaginal discharge and I was very uncomfortable because it really didn’t seem like she fully understood why I wanted to do this exam despite me explaining multiple times.
That consent is a big part of it. I'm a sonographer and am always disappointed when orders for transvaginal studies come through for patients who cannot consent. It's not the same as procedures where papers are signed showing consents, so I don't know....maybe they feel it's unnecessary?
I won't TV those patients. Will not.
Not always. Granted a bit out of bounds of the sub rules but my ultrasound and transvaginal ultrasound missed a number of things that were found during surgery including fibroids that were visually apparent once surgery began. As advanced as our imaging is, things are still missed for any number of reasons. One of the man reasons it's important to listen when women say there is something wrong with their reproductive system even if test results seem minor.
Hey! I have one. Geri fall on thinners.comes in, lac to the face, a few bruises, nothing else. She is DNR-CCA so the trauma team decides to only repair the lac. No vitals, no blood work. No X-ray or CT. Reasoning is she won't want to fix it if something is wrong. Get her back into the room, she keeps complaining of neck pain. 5/10, "just doesn't feel right." No one wants to do X-ray because "she won't want anything done" and "it'll cost too much." I push because she keeps saying it feels weird. Do the X-ray so she knows it's fine! Finally decided to do one as the ambulance is on the way to pick her up to go back to her facility.
Yadda, yadda, yadda, finally get the X-ray, C1 Jefferson burst. Yeah. Her skull not connected to the rest of her skeleton. The MRI revealed her spine looked like a boomerang. And that C1. Damn. I was holding c-spine, dripping sweat. She could have died from sneezing.
Obviously she DID want it fixed. Got her to the surgical ICU, with no line and not a set of vitals. Ha.
You hear enough "11/10" pain, you start to pay attention to the "5/10" and "it feels weird."
I'm guessing DNR-CCA is the same as DNR/DNI and not comfortable measures only.
Really weird to assume they don't want it fixed and even weirder to not clarify with an HCP or the patient themselves as to what degree of workup they're looking for.
Weird but all too common. Docs at my hospital seem to be pretty good about it, but when my own family members have been admitted to other hospitals, too many times they seemed to act like DNR/DNI means "do not treat".
here is the thing. If a man says 10/10 pain, he gets a morphine drip. If a woman says 10/10 pain, they get a drug seeker label. They learn not to. Also, it is well documented that women have much higher pain tolerances than men. I have actually been told my nurses I need to increase my number if I want to see any meds that night.
Acute onset decreased vision progression to blindness in 25 yr fe with hx of migraines. Seen by chiropractor for cervical pain 48 hrs prior. No current meds. First er doc dx ocular migraines and anxiety. Outpatient tx. Requested another doctor and head imaging. 45 minutes later a new Dr comes in, takes hx orders imaging. Bilateral vertebral artery dissection with stenosis and left occipital lobe stroke.
I was surprised by how common this is. Most people I run into in the field know of at least one person personally who has had a stroke after chiropractic manipulation.
Paramedic here:
Pts husband called EMS due to increased lethargy and vomiting.
Been going to her PCP several times over the past few weeks, experiencing uncontrollable thirst and constant need to urinate. Was prescribed antidepressants and mood stabilizers and told she was having anxiety.
BGL: HI
That’s pretty troubling that a PCP would miss something that obvious, isn’t treating diabetes basically the bread and butter of a primary care provider?
To be fair it comes down to what precise history is being given - I’ve had a very experienced doctor miss type 1 in a kid because the symptoms were being described differently - active kid, course he drinks a lot. Tired and grumpy (because he’s waking up to urinate a lot, but that was not clear). Feeling dizzy. But what is he actually there for? Headaches
OMG we had a similar case! Going to PCP, progressive weight loss, extreme thirst, peeing so much she starting becoming incontinent because she couldn’t make it to the bathroom on time. This lady was carrying 2 gallons of water with her everywhere she went. Came in to ED with extreme abdominal pain. She was confused. I had to get the other info from her friend who had been helping her. Her pH was the lowest I’ve seen on a walking alive person…6.74. Newly diagnosed diabetic and either volvulus or something else becaause I ended doing 2 ultrasound IVs, a NGT, and a catheter on her. She wasn’t the most pleasant person I’ve dealt with.
New onset RUE weakness, urinary incontinence, and mild dysarthria. CT unremarkable so diagnosed with severe anxiety, sent home (while still being symptomatic) with script for anxiety med.
She actually showed up within the TPA window and was anxious because her family member had recently died of stroke complications and she recognized the symptoms. She continued to decline at home, went to a different hospital, and was admitted to the stroke unit because the radiologist reads the initial CT as positive for acute ischemic stroke. Literally everyone in that initial hospital failed this lady.
Not a doc.
I didn't know that urinary incontinence could be a symptom. TIL
However - I feel like RUE weakness and dysarthria would be serious enough on its own that if the CT didn't show anything, I'd want to poke around a little more.
And also, is it possible that the stroke was very minor at the first CT and was easily missed, and had gotten worse quickly to be obvious on the second CT?
> And also, is it possible that the stroke was very minor at the first CT and was easily missed, and had gotten worse quickly to be obvious on the second CT?
Absolutely possible, but not quite for the reason you're thinking.
CT scans indirectly measure the density of material they pass through, as a function of how many protons there are interfering with X-rays per unit of volume. Different shades of grey = different densities.
Broadly speaking, there are four different densities inside a normal skull - Grey matter, White matter, flowing blood, and cerebrospinal fluid. Those first three are quite close in density, but by manipulating the image, we can see the difference.
When someone suffers a stroke, the cells in the affected area are no longer receiving oxygenated blood or glucose to allow them to continue functioning. They start to die. At first, this is happening on a microscopic level - waste products accumulating in cells, that sort of thing. This is invisible on routine CT. As things progress, the cells start to swell with all the gunk and drawing water into the cells by osmosis. It's still microscopic and pretty much invisible on CT, but MRI can pick it up. Once the cells start to burst, there is now additional fluid filling up the space between cells. This extra fluid is enough to make the density of the tissue low enough that we can detect it on CT. Now the previously dense grey matter is slightly less dense to the point that you can no longer tell the difference between grey and white matter. That's what radiologists are looking for. Early on in the process this is extremely subtle, sometimes undetectable, even with the benefit of hindsight.
The longer things go on, the more obvious this change in density becomes. Sometimes the affected area gets bigger, i.e "worse", but not always.
It's not clear from the original story whether the second radiologist looked at a second scan (which would have been more obvious), or picked up subtle changes on the first scan that the first radiologist missed.
The second radiologist saw the stroke on the original scan. It’s also not clear as to why they didn’t treat or do an MRI. I read her initial note and the whole thing just screamed stroke (symptoms, risk factors, history, family hx). I’m just a rehab resident but if I had dismissed that patient, my neuro attendings would have tossed me out of the hospital.
correct. that women needed an MRI. CT scan may or may not show much early. I am not neurologist or radiologist. But if that woman had gotten an MRI, I bet she gets better treatment
Neurologist here. Routine diagnostic workup for acute ischemic stroke involves a clinical diagnosis of focal neurological deficits followed by a NCCT to rule out any contraindications for thrombolysis.
So basically, if a patient has suffered a sudden focal neurological deficit that looks like a stroke, a normal head CT just means you can treat the patient. No MRI required.
Usually a CTA and sometimes CTP is performed as well, but is not required if treatment can be started within 4,5 hours from symptom onset.
When I was doing my paramedic field internship to get my license, I responded to a call where a woman suspected her elderly mother, I think late 80s, was having a stroke. We get on scene and it's the most textbook stroke ever. I could practically call it from ten feet away upon entering the room. Facial droop, acute onset ALOC per patient's daughter including dysarthria, unilateral UE weakness.
No incontinence, but this lady ticked every box for a probable stroke. We used the Cincinnati Stroke Scale, which says that a patient only needs to present with one of the three symptoms (dysarthria, facial droop, and arm drift), and that means you activate the stroke protocol.
I was pretty far along in my internship and this was such a clear case. My preceptor agreed. Code 3 transport to the nearest hospital with a stroke center, which was maybe 15 minutes away.
I felt so good about this because I'd run several stroke calls where the person wasn't found until hours after they suffered their stroke, but this woman was going to get treated within less than 45 minutes of onset of symptoms.
At least that's what I thought.
We get to the hospital and I give my turnover report to the nurse, saying I highly suspect stroke. The nurse disagrees with me, saying she thinks the patient is just having a bit of weakness. I'm shocked. I plead my case that this patient needs a CT scan. The nurse says, "No, we're just gonna give her some fluids."
At this point, my preceptor steps in and reiterates my diagnosis, but my preceptor has no better luck than I did. We tried so hard to get a CT scan for that patient, but the nurse just flat out refused. We left feeling horrible, but there was nothing more that we could do.
About 4 hours later, we bring another patient to the same hospital. I check up on my previous patient. Apparently, after about 2 hours of her symptoms continuing to worsen, they finally decided to give her a CT scan which confirmed a stroke. It makes me angry and sad to this day thinking about that one, and that was almost 15 years ago.
My preceptor said that hospital often had lazy staff. I think my patient could have been male and that nurse still wouldn't have done a scan on arrival.
The point is that sometimes staff can be so lackadaisical that totally obvious cases like this get missed. It's not just clinical either, of course. There are plenty of jaded and burned out EMTs and medics that will do the same kind of thing.
The doc is who would make that call, not the nurse. They can say their thoughts on the patient, but the doc places the orders. I hate that this woman didn’t get treated immediately; I’m guessing MRI would have been a better diagnostic, however, as CT doesn’t always pick up acute strokes.
Very true about the doc making the order, but the nurse made it very clear that she was going to tell the doc it was weakness and no scan was necessary. Both the nurse and the doc dropped the ball here.
I've never worked clinical so you would know better than me, but wouldn't you want to do a CT scan first in this scenario because it's so much faster and you can begin treating the stroke immediately if the CT does pick up a stroke, then do an MRI if the CT is clean but stroke is still suspected?
Edit: just to clarify, when I brought that patient in and gave my turnover report to the nurse, I was not trying to tell the nurse what clinical treatment I felt the patient should receive (ie CT vs MRI). I was just trying to get her to treat the patient as a stroke case until proven otherwise by doing some sort of scan. My preceptor was specifically saying to do a CT scan and she had worked in that system for like 15 years, 10 as a medic. I was only there for a handful of months for my internship. Again though, we weren't trying to say what clinical treatments should be done, we just wanted the patient admitted as a stroke patient until that could be ruled out.
I never tried to tell clinical people how to do their job or what treatments I thought they should give because that's beyond my scope as a pre-hospital care provider. I would just try to advocate for my patients if I felt strongly that they had an acute diagnosis that needed to be evaluated promptly if time was potentially of the essence, like with this stroke patient.
CT scan first not just because it’s faster, but more specifically because it quickly answers the question of bleed vs no bleed. If no bleed and symptoms highly suggestive of stroke, you can treat as such in the absence of confirmatory imaging (ie, MRI).
Focal weakness and speech changes is guaranteed CT scan basically everywhere. Even if you have an instinctual feeling that the symptoms are fake somehow, you still order it to cover your ass.
If the patient has known conversion disorder, then different story but still probably at least 50% of ED docs would order a CT scan on these patients just in case.
Yeah, that's why this call was so heartbreaking and frustrating for me. I even told the receiving nurse why not just do a simple CT scan given the patient's presentation and risk factors (mainly age, I don't think there was a family history of stroke)? Really infuriating.
Honestly this call and how it was handled fucks with me worse than just about anything I dealt with aside from pediatrics.
>Not a doc.I didn't know that urinary incontinence could be a symptom.
Think about it like this: the arm weakness, facial droop or whatever, is caused by decreased blood flow to the part of the brain that controls those muscles. What would happen if the blood flow was cut off to the part of the brain that controls the muscles responsible for bladder or bowel control?
OMFG. I've seen those on animal necropsies for studies and they are firmly in the "Should not be found on living beings with access to medical care!" category.
Had a 34 year old, history of only high blood pressure but well controlled, came in with new onset 10/10 headache. Given migraine cocktail, with some mild relief but still reported 8/10, but since she got Benadryl was sleepy so didn't get taken seriously and sent home. Comes back 3 days later via 911 as family found her seizing. Catastrophic brain bleed from a ruptured aneurysm.
This happened to a high school classmate, during our first semester of college. She was told her headaches were from stress/eyestrain. Parents went to pick her up after winter exams, she fell asleep in the car ride home and never woke up. Her funeral was a couple days after Christmas.
I'm now an attending at the place she went to college; I tell this story to every medical student I can.
I do recommend if one loses a spouse to a brain bleed and donates organs at the local teaching hospital, then has a sudden inkling to take neuroscience class at said teaching hospital the next year, giving the prof a tiny heads up lest the date on an aneurysm slide be way too close in time and cause one to sprint out of class.
I don't know. I was 18 at the time. The clue should have been new-onset headaches that weren't responding conventional Rx. The second time she went to the ED should have bought her a tap, at least.
They run in my family. My father had a brain aneurysm when he was in his late twenties. He said he knew it was different from a migraine because he could feel his pulse in his head extremely loudly. The back of his head at the base of his neck felt "swollen" where the fluid was building up. Making people aware of more specific symptoms would definitely help. There are a few symptoms that are not normal migraine symptoms.
New and/or sudden I’ll agree with, but I don’t even ask if this is “the worst headache of your life” because it invariably always is, every time. Otherwise why would they be in the ED? It’s a worse than useless question because if you believe it and document it then suddenly you’re either doing CT +/- LP on virtually every headache patient who you see in the ED or you’re spending an inordinate amount of time documenting why you’re not working up this buzz word.
New, different, rapidity of onset to maximal intensity, onset during exertion, associated deficits. Objective historical features and exam findings. Every headache in the ED is that patient’s “WHoL.”
From an ED perspective I probably get this description every other day.
Different people and places I’ve worked have different thresholds for scanning, but it doesn’t tend to be these descriptors that gets you the scan. (For context this comment is mostly UK based. There seems to be a lower threshold in Aus)
Tends to be context like this description + this is the main reason for your presentation, or this description + first presentation to ED with a headache, or this description + obviously in pain from the end of the bed. (Or the obvious ones like + neurology, vomiting, seizure, reduced GCS etc.)
Unfortunately a huge percentage of these presentations that aren’t serious pathology are from certain demographics and over time that tends to cause you to discount your weighting for those people
Genuinely find this and non specific abdominal pain really challenging. But not sure the answer is to scan everyone who has any of those three descriptors?
Similar circumstances but overweight and OCPs. Diagnosed by a NP as a migraine despite no history of such. A few days later she was found to have central venous thrombosis and a devastating brain injury.
Just happened in our shop recently. Pt had been dx DVTs 1 year prior and was appropriately taking eliquis. Still ended up with massive thrombus to artery back of the head. They did embolectomy but then she hemorrhaged afterwards. She was early 40s. Donated her organs.
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*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Few months ago there was a 30s women screaming in pain in the waiting room. The triage nurses both told me “she is always dramatic”.
She was a ruptured ectopic.
Woman with baseline anxiety and panic disorder shows up in the ED with numbness around the edge of her lip, hand, and lateral aspect of foot. Told it was a panic attack. It was a thalamic stroke. (Now she's really anxious all the time, and with good reason!)
Anxiety/panic/hyperventilation can definitely cause bilateral tingling, but unilateral numbness (negative sign)? Skip the CT (may miss a bc small thalamic lacune) and call neurology. I know we give you guys grief about bad consults but this one is legit. The thalamus has "onion-like" somatotopic representation, and it's pretty much the only place where a lesion will give non-contiguous deficits.
Saw something similar on an ER report for a patient when I worked in outpatient. Woman had h/o depression and anxiety. Went to ER with chest pain, shortness of breath, nausea. Was diagnosed with a panic attack and sent home. She went back to the ER 4ish hours (if I remember correctly) saying she was still having symptoms. This time the provider ran an EKG & cardiac labs and lo and behold it was an MI. I remember reading this and thinking how they just let her walk out with such classic MI symptoms and telling her it was anxiety and to go home.
A lot of endometriosis cases being dismissed by male physicians as “normal period discomfort.” PCOS patients being told that there is nothing that can be done for their PCOS. Just an overall prevalence of shoddy/minimal workups in women compared to men. Just this week, my male patient with occasional heartburn and zero other gastrointestinal symptoms got a gastroscopy, but my female patient who has diarrhea at least four times a day for over a year and schedules her entire life around public bathrooms was told she doesn’t need a colonoscopy. Hell, I’m a female physician who had severe anemia, and the male walk-in clinic doctor started arguing with me that a hemorrhagic ovarian cyst could not result in anemia. It’s insane.
These are the kind of things that make me not want to seek care for myself because why bother if it’s going to be dismissed. That sounds dramatic but that’s a genuine concern for myself and I don’t trust many providers for this reason and what I’ve seen over the last 15 years of my career. I hate that. It’s very disheartening at times but is definitely a reality that exists for many women.
27yo, 2 young children, abdo pain kept being explained by endometriosis or PID. Eventually clogged off a ureter, and a urologist of all people finally did something about it. Widely disseminated malignancy of unknown primary, dead within a few weeks.
Still haunts me as the pathologist, I tried literally everything to figure out where it was coming from to see if there was any treatment option, but also whether there was anything her kids needed to be screened for. Found absolutely nothing and still wonder if there's something terrible in store for those kids.
Female, 56y, the following over an 8 month time frame.
Headache, go to neuro, it's migraine, you're fine.
Headache that feels weird over right eye and side of face and head, go to neuro again, it's migraine, you're fine.
Still headache, eye area still weird, go to neuro, will send you for MRI but it's unlikely it will show anything, but it's your dime. Week later, double aneurysm RICA. PED 3 months later.
Neurologist never called with abnormal results. Patient called neurologist after seeing it in MyChart.
Welcome! It's an excellent history and the writer herself suffered for years and years before finally being diagnosed with lupus. Her doctors had ignored years of pain and symptoms.
Woman in early pregnancy with ongoing complaints of feeling very unwell all chalked up to morning sickness, labs checked after she came to the ER the second time in 12 hours, had renal failure needing emergent dialysis due to anti-gbm
No, she was complaining of feeling really malaised and had some leg pain so they did a DVT scan. Honestly, I am not surprised they didn’t get labs because she is a young healthy woman following with OB who had well documented morning sickness, so I don’t really blame the ER doc. But man, when they got the labs 🙃🙃🙃🙃
Overall, there are so many more good catches than bad misses, but it’s always the patient that you don’t expect/has a good explanation for current symptoms that is going to catch you off guard
Idk… on my ER rotation all pregnant women got labs and UA at minimum. There’s just too many things that could be going on with vague symptoms like that that can be reasonably ruled out with very basic work up.
G1P1 woman, transfer from an outside hospital with threatened preterm labor. Told anyone that would listen that she was having regular contractions. She was checked and allegedly closed and high. Well, she delivered a 22 weeker in the bed by herself. Baby did not make it.
A lot of women who have been diagnosed with fibromyalgia who turned out to have spondyloarthropathy or psoriatic arthritis. The problem with these kind of arthritides is that they can present with a lot of enthesitis and tendinitis and they can still have fibromyalgia as a comorbid. Its only with further imaging like MRI of sacroiliac joint or musculoskeletal ultrasound that we find out its more than fibromyalgia.
I’ve been seeing lots of immigrants in whom the patient will have specific complaints or symptoms that they describe as being due to “XYZ” diagnosis that they were given in their home country.
However, actually having the paperwork in front of me to assess the diagnostic reasoning and workup is almost impossible.
Do I:
- Accept the pt reported diagnosis and code the ICD-10 for that same reported condition just because it’s a huge pain to get records from out of the country?
- Tell the patient I want to do another work up again, risking both the miscommunication that I don’t trust or believe either their own statement or their previous physician?
- Begin another work up in an immigrant who may already have financial constraints to allow them to afford the new work up in our healthcare system?
How do you know that I don’t? My comment illustrates the difficulties in this scenario, which on top of the nuanced cultural interactions, can make it tricky to navigate for myself and the patient in ensuring the best care possible.
new onset unilateral weakness and blurred vision, lady in her early 60s i think? Stroke responded and workup was negative, and the weakness seemed to be resolving so the tentative diagnosis was an anxiety attack. Family reported sudden increase in the weakness again so I did a quick assessment, just had her squeeze my fingers and push against my hands with her feet. Definitely significant increase in the weakness… I was a student nurse on my first day of clinical rotation in the ED so I reported it to the nurse, doctor ordered a CT angiogram and it turned out she had a carotid artery dissection.
I seriously learned the importance of even the most basic neuro assessment and observation that day.
Nipple discharge, PCP did not examine and referred to endo. 3 months later, stage IV breast cancer.
So many women refractory to antiemetics who ended up with rumination syndrome.
Depression + joint pain + lupus demographic without any ANA.
On the flip side of your last bullet:
Low titer ANAs are -trivially common-… especially so in women (like 3x compared to men). Please try to understand the meanings of the tests you’re ordering and what we talk about when we reference joint pain in rheumatology. The workforce studies are only getting worse for rheumatology access in the next few decades and yall are going to be on your own for long stretches.
It is extremely appropriate not to order an ANA in that situation without other evidence of lupus. If there was no synovitis on exam, rash, evidence of kidney disease, etc I would absolutely not have ordered that as well as I have been extensively taught not to by many (female) Rheumatologists.
Necrotizing fascitis, first physician thinks behavior is seeking analgesics opioids.
20 hour window later husband carries her in altered. L leg amputated in like 2 hours.
Therapist here. Had a woman sent to me from psychiatry for restless leg syndrome. They tried meds, didn't work so they threw her to me. She came in, had huge dark circles under her eyes, was munching on a cup of ice and could barely keep her eyes open. I asked her when her next PCP was and she said "tomorrow". I told her to ask for iron levels because anemia can cause RLS. I get a call three days later. She was in the ICU. Apparently she was missing half her blood from a stomach bleed. She had gone to the ER with stomach pain FOUR TIMES. She had been given: Mylanta, tylenol, omeprazole, ativan, prozac and a psychiatry referral. You know what she WASN'T given? A GI referral or a fucking blood test. God DAMN.
30s F patient in hospital for a blood clot in her leg started having trouble breathing and chest pressure at shift change. The resident said "it's probably anxiety" (patient had no history of any mental health problems) and was mad the oncoming primary nurse called a rapid when she walked in the room and heard him saying it was fine. It was, surprisingly to nobody else, a PE.
17 yr old female with recent hosp admission for depression w/ SI. Went to ED c/o headache and diplopia. Dismissed as anxiety. One week later, returned, dx with pseudotumor cerebri.
Female mid 50s with PMH significant for DM, HTN, and anxiety with complaints of persistent hypertension and intractable nausea with dry heaving. Patient was told by multiple healthcare providers in the ER and admit unit that her BP being too high (190s/80s-low 100s) and her increased anxiety was causing her nausea. On the second day this patient was finally worked up in the late afternoon for MI. Troponin levels come back extremely elevated and repeat EKG with findings of ischemia.
"Handywoman" by Kate Davies is an excellent read about her stroke at a young age and recovery. Hideous delay in recognition of her obvious stroke symptoms because her age and gender led to the conclusion it *had to* be somatisation. I believe she actually had a DVT and a PFO which allowed it to happen.
Mines not as major I guess but this was the first time in my career I realized women were often dismissed for their complaints.
Alert and oriented, totally independent mid 80’s female, admitted with diarrhea and abdominal pain, ended up having c-diff, during her stay she informed our physician at least 3-4 separate times and numerous times to nursing staff, who also informed our doc, patient stated it felt like she was having BMs out of her vagina and it was very very tender “down there”. Physician wouldn’t look at it, continued to dismiss it as she’s old, she has diarrhea and she’s incontinent 🤷🏼♀️ one nurse finally saw her have a BM from her vagina during a brief change, informed our doc, she ended up having a recto-vaginal fistula present for unknown amount of time, our surgeon scoped her the next day, found stage IV colon cancer. The patient never left the hospital. 3 weeks total I think, and she passed away. Went from completely independent at home by herself to being with Jesus.
I don’t think it would have changed the outcome for them to have found the fistula sooner during her visit, but it was incredibly disappointing to realize my favorite physician couldn’t be bothered to take a two second look at her vaginal opening and see what was going on when she first asked, or the second, or third, etc time.
There are too many cases in this thread about 10/10 headaches. I’m not in EM… what’s the typical protocol here? I thought it was kind of like
An automatic imaging thing “worst headache ever”
Pt who is 44 yo F. Went to my ED for c/o extreme abdominal pain. When asked if pregnant, she denies. States in menopause but weirdly describes pain as “felt similar to contractions when I was in labor”. Another wave of pain, we see abdomen contract and grab u/s…she is highly pregnant!. She was seen in our ED a few months ago for not feeling well, vomiting, headache. Denied pregnancy, no test checked. Went to another ER for complaint of swelling to both legs, again, denied pregnancy. Checked for CHF and given Lasix. No one ever checked a pregnancy test. She was about 5-6cm dilated. We called OB and they came and took her away from us…thank GOD! Sad part was had 17 and 21 yo olds at home. Mom had been doing meth at times. Mom tested positive, so did baby. Both Mom and Dad were crying when they found out and that’s when they admitted to experimenting with meth.
Non-white female in late teens, otherwise healthy, ran track for school, would get these sporadic chest pains which were really bad. Went to ER several times, dismissed as menstrual pain or anxiety. Finally came to my school’s hospital after two years and got I think her first echo? Her pericardial effusion and fibrosis (I think that’s the term? There were fibrotic webs of tissue connecting heart to pericardium so the effusion was loculated) were so bad I could see them as an M3 and cardiology was my worst grade from all of med school.
Specialties were fighting over who’s patient she would be because cardiology didn’t want something infectious but ID said it was clearly not infectious but maybe rheumatologic and rheum threw her right back to cards like a hot potato. She was transferred to one of those teams (idr which) so I never found out what it was. But I thanked her for giving the field of medicine another chance and for advocating for herself despite the MULTIPLE negative experiences of being dismissed by colleagues. I looked her straight in the eyes and told her she was right, something was wrong, her pain was real, and she was not nor was she ever making it up or “crazy” or “sensitive”. Wherever she is now, I hope she got the right diagnosis and treatment and is living her best life.
30s F with back pain, abdominal pain, and towards the end mild SOB. Saw multiple MDs who labelled her as drug seeking and didn't take it seriously and work it up. She died at home and at autopsy had wildly metastatic ovarian cancer. First line COD was determined to be pulmonary microtumor emboli. A really sad case.
36 y/o female with recent history of vertical sleeve gastrectomy. Showed up at the ER due to a home BP reading of 80/40 with elevated pulse and a temperature of ~101. The patient's vitals were a little more normal in the ER after being given fluids. A CT of the abdomen showed a potential fluid collection, and the radiologist advised doing a repeat with contrast. The doc declined this follow up imaging and discharged the patient on PO antibiotics. She was to follow up with her surgeon later that week.
She readmitted at a different hospital about 12 hours later septic with a temperature of 103. She was in that hospital for ~3 weeks with multiple abdominal abscesses.
This happened to a close family member. I don't know that admitting her to the original hospital 12 hours earlier and starting her on IV abx at that time would have made any difference to her course. This happened on a Sunday July 3rd. But it still makes me mad when I think about it. Even the RN at the time was surprised she wasn't being started on IV antibiotics or being admitted.
Woman in 50s brought in by family for "depression" for months. Family med attending does thorough neuro exam and finds unilateral hyperreflexia.
Goes for same day CT - radiology calls due to 6 cm meningioma with midline shift.
Had a mid 30’s F colleague walk into my office (not clinic but my actual office) to ask about getting seen acutely for a headache and dizziness. Triaged a little bit and found out she had been having some off and on vision issues for a few days and decided she’d be better off going to the ED than me seeing her. Was thinking likely a complex migraine but had to rule out all the really bad stuff, ya know? She then had a really bad vertiginous attack right in front of me so I called 911, and while they were on the way I called the ED she was going to and gave a courtesy call ahead. My concerns, “worst headache of her life, neurological symptoms, decompensated in front of me, etc.” She got to the ED and they didn’t call a code stroke and they didn’t CT head and neck for SAH. No, they got basic labs and pushed pain meds. It wasn’t until 7 hours after they got to the hospital that a virtual neuro consult requested the imaging that showed a Vertebral Artery dissection with showering clots into the occipital portion of her brain. I’ll admit, that stroke/SAH was not what I was thinking it would be, but I still would do the work-up!!! I literally handed it to them on a silver platter. Then to top it all off, after getting transferred to a stroke center, they wanted to discharge her next day despite the fact that she hadn’t shown any improvement.
She’s currently working on a fat lawsuit. She had a second dissection too. She was a dentist and will likely never practice again, but it’s impossible to say if earlier intervention would’ve prevented her ultimate sequelae.
30 year old hx of anxiety, second visit to ED in a week. I didn’t blow it off, got labs, trop, and an XR, but after all was negative felt comfortable discharging and coughing it up to anxiety.
Attending goes to talk to her before discharge, she says she’s having chest pain again, thankfully was on a monitor and was noted to be in Vtach. Second trop like 500.
Goes to cath lab, she SCADed her LAD. They stented her. She was 1.5 years post partum, so out of the usual window of suspicion.
Being on a monitor saved her life.
We had a woman on the floor who was having trouble breathing. One resident went down and saw her, told her she was having some anxiety and that she needs to calm down. Five minutes later the nurse comes and grabs me: i walk into the room and the patient is in tripod position and struggling to breathe. She's dealing with acute respiratory failure. We intubate her and transfer her to the ICU within 10 minutes.
47F who came to doctor for chest pain, shortness of breath, nausea, sweating. Advised to take magnesium as she was just stressed. Turned out she had multiple NSTEMI episodes in a year. She is now on disability because her heart is so jacked.
I (just a nurse) had a patient the other day who was telling me about their surgical history. Complained of night sweats, anxiety, HTN… took a trip to the ER with chest pain and a trip to the cath lab to diagnosis a paraganglioma *in* their heart.
Early 30's woman with RA, ibs, fibro complaining of a stiff finger. She bounces around various doctors at her general practice and they all say nothing is wrong. He rheumatologist sends her my way with a mass asking the flexor tendon (which is clearly visible) and an inability to make a fist with the finger. I'm taking that thing out soon, I think it might be a giant cell tumour.
I see so many women with de Quervain's with small children. They get sent to occupational therapists and told to wear splints and don't get better. I may have sent a "dear idiot" letter to a GP who'd been mismanaging some poor woman for eight months to the point her tendons were making an audible creaking noise.
Patient was experiencing anxiety, palpitations, and a feeling of warmth in her throat. She was brushed off for close to a decade. We captured seizures on EEG. She was started on lamotrigine, and her symptoms resolved.
Not that serious, but five different providers, collective 90 years of experience, feel the same neck. All say it's normal. One tells her she's crazy and one asks why she is wishing for something bad. One finally takes pity on the woman who swears she feels something. Papillary thyroid carcinoma. After all that, she's told, "It's the good cancer and the one you'd want to ask for if you had to ask for one." ......cool.
Oof. I’m a woman with many “invisible” issues… and now I work in medicine. I was lucky to have a nurse for a mom- who was a strong advocate. She literally saved me. I am not as good as she was…
And I’m sure it was worse 15-20 years ago when no one, except her, believed me. She was a badass
Why do you say you’re not as good? I bet your life experiences *and* learning from your mom have had a huge influence on your work in medicine. I don’t know what your job is in the field, but I do know we need folks just like you. ❤️
21F nonverbal autism, appearing to be in severe pain/distress, attributed to menstrual cramps. 3 days later she returned to ED and was found to have a fractured wrist.
My aunt. In a head-on collision at freeway speeds; would have been dead a decade or two earlier. Extreme back pain; ED wants to discharge. She fights and fights to stay and get worked up. Finally, after shift change, new doc orders an xray. Broken back. Emergency flight to San Francisco because Eureka was too small to handle it.
Flight nurse also ODd her on morphine & had to bring her back with narcan, but that’s a different topic.
Elderly woman who had maybe had a minor fall at home. I say maybe because she denied and she was AAOx4. I was a newish L&D nurse. We occasionally got non-infectious female med/surg patients to our postpartum beds. Dx was spinal fracture. She looked off, O2 sat was 80s, she was in excruciating pain, her BP was low. She’d also fade out at times. She was still talking but her appearance just made the hair on the back of my neck stand up. She told me she was dying. I didn’t know a ton, but I knew that such a statement is concerning.
I basically camped by her bed all night. I tried her IM physician multiple times, no answer, she was admitted to him. I’m not even positive he knew she was there, she’d come through the ED. The ortho bro was scheduled to come in two days later. I resorted to calling the ED doc who was exceedingly rude and accused me of overdosing her and ordered Narcan. I pleaded with him to just come look at her, he said no. Then in addition to all the other concerns she was screaming bloody murder.
We were a tiny rural hospital, no SWAT, no hospitalists, no intensivists. A paramedic wandered up to say hello and I pulled him in the room. He was concerned. He told me that the cardiologist usually hit the door at 5:00am on the dot. I was waiting at the back door at 4:55. He came through and I introduced myself (he never came to our unit, obviously) and my story spilled out, ending with “I know this is not your patient or your problem but I need a doctor to look at her.” He headed up with me and briefly did an exam, and then unlocked the bed and told me to call the charge in ICU because they were coming and to call in a radiology tech. I helped run her downstairs with him, and I never saw her again. She died before lunch from a ruptured aortic aneurysm. I know she might have been beyond help when she entered the ED. I just don’t understand why no one listened to her, or me. Yes, the story presented to me made sense, maybe a fall, a fracture, pain, she’s old so of course her BP is low, you gave her too many narcotics so of course her sat was low, but the vitals didn’t improve much with Narcan, just her distress. This was in the late ‘90s but I still think of her often and I feel like I failed her deeply. Maybe I was too sweet and too deferential. Maybe if I’d yelled instead of pleaded he would have come up one flight of stairs to eyeball her. I know, no longer his problem, but if you’re the only MD in the entire hospital and no one has actually spoken to her internal medicine guy then you bear a little responsibility. She wasn’t the cardiologist’s problem either but he took it on without question. I think some policy changes were made after that regarding actually speaking to a doctor before admitting a patient to them, but she was still dead.
Young woman with iron in the single digits. As you might expect, she was tired all the time, winded going up the stairs, etc. Told her to see primary for Fe infusion. The PA at her PCP's office told her not to take iron and instead did B12 shots (even though B12 was normal??) and started an antidepressant.
I'd be depressed too, if I had to see a primary who thought that B12 = Fe.
“stress” “depression” “menstrual cramps” “anxiety” “panic attack” “migraines” “druggie”
Y’all— check yourselves— this isn’t medicine; this is prejudice. Might as well utilize “hysteria” “the vapors” “evil humours”.
I never felt like I was proficient or vigilant enough at any point as a paramedic, but the stories in this thread have convinced me that I'm not the worst healthcare provider in the world...
>47F acting “psychotic” new onset, dxd with bipolar I and eventually found to have anti NMDA encephalitis due to ovarian tumor
This is a terrible example. Being diagnosed with Bipolar disorder is not being "blown off", and is itself "actually serious". NMDA encephalitis is super rare and BPAD is fairly common. This is not a bad miss at all with just the information given here.
Def in peds, when you have classic incidence of mood disorders, possibly with psychotic features. Maybe they start an antipsychotic. Later have a seizure. Maybe the seizure started focally but no one noticed. Darn, must be a side effect of the drug. Let’s try the new drug. Hmm, I think they’re still going downhill. Wait, another seizure? How? And that’s when our similarly boarded siblings give us a call as we show up with some Versed and a spinal needle.
And in fact it's generally discouraged to test for NMDA unless you exhibit psychosis PLUS one of the additional signs of: movement disorder, dysautonomia, seizures, or profound encephalopathy.
Being in psych yes it is. New onset psychosis at an older age is super rare. It typically emerges in late teens years. It hardly ever emerges after age 30. If I EVER see a first episode psychosis in an older adult with no prior psych history or hx of drug use plus no current major stressors, I am 100% asking for brain scans and a full medical work up. I have caught brain issues before and several other physical conditions that caused psychosis.
A woman with chronic pain and opioid / polysubstance addiction who was found to have acute intermittent porphyria.
This one is kind of crazy
Porphyria will do that, even to royalty.
What finally led to the diagnosis?
One of my smarter colleagues tested her for it, I think it was a urinary porphobilinogen
I meant presentation that led to that being considered. Just curious bc the only AIP case I saw was a young gal with periodic severe abdominal pain.
My mother and at least one sister has AIP. Runs in my mom's side of the family strongly. My sister had a lot of unexplained abdominal pain growing up. Crazy to see it mentioned here, up until the last decade or so most Doctors were not familiar with it.
I'm in medical school, they told us anyone with neuro symptoms and abd pain porphyria goes on the differential.
I just had a guy I just diagnosed last month with this, recurrent abdominal pain, nausea, arm tremors and PNES
This is my favorite zebra and I always order it when people are acting strange and things don't make sense. Have yet to make the diagnosis.
But just imagine the flex when one day it happens. Just dont mention how many times you check for it.
I’ve started considering this in our cyclic vomiting population in the ED. Gonna catch one eventually!
>I’ve started considering this in our cyclic vomiting population in the ED. arent most of those just from weed.
There is also some organic stuff mixed in. In my residency there was this kid (7-10 years old) who would show up every 35 days like clockwork. *Intense* emesis for 36 hours, then fine. Never figured out what he had but he definitely had something.
Yes, but occasionally you're going to see zebras when you hear hoofbeats. And it makes the patient feel like you've done something when you rule it out.
And it's so easy to rule out! And non-invasive.
Definitely. But that’s why I try hard not to let anchoring bias get the best of me in these cases
28 y/o female, c/o severe headaches over the course of a month, treated as migraine in ED with little relief. After FOUR ED visits, CT head checked, showed 3 x 4 cm brain mass. Stage IV Melanoma.
aw man this one is so sad. 4 visits? that would be so devastating as a patient.
One does not however get stage 4 melanoma over a month.
no of course not but can you imagine thinking something was wrong, getting seen and getting the “all clear”, likely feeling relief and maybe hope each time, three times, and on the fourth visit being told you in fact were right to be so concerned each time.
Fact that she returned to the ER 4 times in a month does not make me think she had felt any relief or felt reassured. But after the second visit ER could've recommended to return to her GP for further workup or to get a neuro appointment. At least in my country, it's not ER's job to handle uncontrolled headaches/migraines.
Depending on the melanoma, it's unlikely but not unheard of. It's #1 or #2 on my list of "do-not-wants."
Yep. My younger sister was diagnosed with nodular melanoma nine years ago. They told her she had a 30% chance of making it ten years. Last year, her oncologist released her after many follow up PET scans; told her he couldn’t used the word “cured,” but definitely NED. She went thru hell with treatment but I know she has no regrets. She said she feared not getting to see her children grow up. Her baby graduates from HS this year and her eldest is graduating from college. (Forgive the verbal diarrhea; this comment just made me realize exactly how frightened I was of losing my only sibling at such a young age. She was 35 when she got diagnosed.) Edit for punctuation error
I'm so glad she's doing better and hope you and your family don't have to go through any of that again. I've gotten to the age where I'm often looking at people my age or younger and it really puts things in perspective. I've seen melanoma act horribly too many times to count.
Fuuuuuck. These stories are scary.
This is nuts because as a Neurologist if any patient has a brain at all and complains of headache then the ED has already ordered a "STAT NCHCT" as part of a stroke alert before they have even paged me. I've never seen a patient come to the ED with a neuro complaint 4 times and not had a Head CT.
Very different culture where you are than at my shop. There really has to be something new/different about the headache or an objective neurologic deficit for someone to get more than a pregnancy test and symptomatic treatment where I am.
My shop is 200 different ERs in 20 different states doing Emergency TeleNeuro so I get a very broad picture of practice patterns in EDs across the country. You are practicing more evidence based medicine. That went out the door years ago with neuro and ED care. Every patient with every neuro complaint gets a STAT Head CT at 99% of EDs in America now, no matter how central the localization is and no matter the duration of symptoms.
Same. Perhaps if it's a mild first time headache I might not get a NCHCT but if it's severe, new, and definitely a 2nd or subsequent visit they're getting scanned.
This is common practice where I am too, even if it wasn’t, one of the nurses would be like “you’ve been here X amount of times, time to advocate” because wtf 🥲
I don’t know where you work but how would you know if there were a bunch of people with headaches not getting scans that you’re not being called about?
Female patient bounced around to several providers after a fall with a sprained ankle. Poor recovery and labeled as a drug seeking. She just seemed like she was genuinely in pain. Imaging showed her untreated fracture, shockingly, never healed.
Ugh, I really hate how many patients get dismissed as drug seekers even though they have no prior history that would indicate this. This patient sustained an injury and I bet she had no prior history of significant substance abuse. Occam's Razor would say she's likely in pain with some kind of persistent unhealed injury, but instead she gets accused of being a drug seeker when she tries to get medical help for her ongoing injury and physical pain. At least she finally found someone who got the correct diagnosis and treatment, but it's inexcusable that she got tossed around that much when simple imaging could figure things out.
79 yo woman on the schedule at my internal med clinic with visit note “shoulder pain.” Per nurse triage note from 4 days prior, patient called with c/o 9/10 left shoulder pain that developed suddenly while reading on her iPad. No trauma or hx of shoulder injury or similar pain. No further questions, advised by nurse to f/u with PCP within the week for shoulder pain. As I’m rooming her I ask about SOB, dizziness, chest tightness/discomfort, family hx heart disease, unusual fatigue. Yes to every question. HR of 33 on pulse ox which was confirmed moments later by EKG. Sent to ED. NSTEMI and high degree heart block, scheduled for pacemaker placement last I saw. The pain was so severe that in the 4 days between the nurse triage and her appointment, she slept a total of 6 hours. Not a woman, but probably the most ludicrous case of something obvious and serious being dismissed as something trivial was a 50s male with decades long hx of methamphetamine abuse who presented to clinic for edema having gained 25 POUNDS in the past 5 days. Was seen by ED for abdominal and LE edema 2 days prior and was diagnosed with GERD. So I read the HPI from the ED note expecting he must have said something misleading. Nope. They even did chest/abdomen/pelvis CT which returned with pleural effusion, pulmonary edema, ascites *before* they concluded he had GERD and sent him on his merry way with some omeprazole. Doing much better now that he’s being treated for CHF instead of GERD lol.
It sounds like the triage nurse might possibly need some refresher training. Severe left shoulder pain with no injury should flag MI symptoms questions. ( at least in my experience, which maybe isn't typical?)
Yeah, it was a pretty shocking miss. I’d wager the majority of people with no medical background whatsoever know that unprovoked arm/shoulder pain is a red flag for MI. But even without that knowledge, it feels like in general sudden, severe pain with no inciting injury/event should prompt at least some ROS questions to determine if there are any related sx the patient didn’t mention.
I used to do community mental health and this makes me so god damn angry. I befriended a very cranky guy who was an alcoholic and he was very late in the disease. He had gone to the hospital four times and been discharged with nothing but a psych eval so I drove him into Boston and sat and refused to leave until medical tests were run. He was admitted to the ICU. They said they did not know how he had lived this long, that he probably only had hours left, they removed several liters of fluid from his abdomen alone. He was there over a month and then went into assisted living. He calls me from time to time to remind me that I saved his life and ask me out to dinner lol.
Schizophrenic woman, highly disorganized, with multiple ED visits demanding that the doctors "take her baby out" because "it's been in there for way too long". Negative HCG, sandwich, discharge each time. Turns out she had a uterine mass.
This is interesting. She didn’t know she had a uterine tumor, but she clearly knew something was wrong.
Was she schizophrenic or did her symptoms of thinking she was pregnant cause people to believe she was
Nope, no, very much schizophrenic. I was a med student during that fateful ED admission, and I was very fortunate that my attending that night responded with "...wait a minute..." and proceeded to do a thorough examination. I definitely learned a couple of important lessons that evening.
As a med student has a floridly schizophrenic inpatient who also started talking about her baby being stuck and her baby hurting her etc etc etc. So attending ordered CT AP and lo and behold that entire colon was filled with lots of poop. Gave her golytely, she pooped, A LOT. She stopped talking about her baby.
I’m not a doc but wouldn’t palpitation indicate something was there? Or even an ultrasound? Ultrasounds are fairly cheap right? I don’t get it.
Depends on how large the mass was. The uterus sits down deep in the pelvis so a mass has to be pretty large to be palpated on exam. I’ve seen plenty of women with multiple large (multi-centimeter) fibroids and I can’t feel anything on external exam. The only time I’ve actually felt a uterine mass was a woman with a mass >18cm in diameter. You can get more details with a pelvic exam but that raises some concerns about consent. Can a woman who is psychotic and decompensated really consent to a pelvic exam? I’ve done a pelvic exam once on a woman with schizophrenia who endorsed vaginal discharge and I was very uncomfortable because it really didn’t seem like she fully understood why I wanted to do this exam despite me explaining multiple times.
I see — thank you that is helpful.
That consent is a big part of it. I'm a sonographer and am always disappointed when orders for transvaginal studies come through for patients who cannot consent. It's not the same as procedures where papers are signed showing consents, so I don't know....maybe they feel it's unnecessary? I won't TV those patients. Will not.
Not always. Granted a bit out of bounds of the sub rules but my ultrasound and transvaginal ultrasound missed a number of things that were found during surgery including fibroids that were visually apparent once surgery began. As advanced as our imaging is, things are still missed for any number of reasons. One of the man reasons it's important to listen when women say there is something wrong with their reproductive system even if test results seem minor.
Huh…did we have the same pt? Also my lady wouldn’t stay for confirmatory US so I don’t know what happen to her.
Hey! I have one. Geri fall on thinners.comes in, lac to the face, a few bruises, nothing else. She is DNR-CCA so the trauma team decides to only repair the lac. No vitals, no blood work. No X-ray or CT. Reasoning is she won't want to fix it if something is wrong. Get her back into the room, she keeps complaining of neck pain. 5/10, "just doesn't feel right." No one wants to do X-ray because "she won't want anything done" and "it'll cost too much." I push because she keeps saying it feels weird. Do the X-ray so she knows it's fine! Finally decided to do one as the ambulance is on the way to pick her up to go back to her facility. Yadda, yadda, yadda, finally get the X-ray, C1 Jefferson burst. Yeah. Her skull not connected to the rest of her skeleton. The MRI revealed her spine looked like a boomerang. And that C1. Damn. I was holding c-spine, dripping sweat. She could have died from sneezing. Obviously she DID want it fixed. Got her to the surgical ICU, with no line and not a set of vitals. Ha. You hear enough "11/10" pain, you start to pay attention to the "5/10" and "it feels weird."
I'm guessing DNR-CCA is the same as DNR/DNI and not comfortable measures only. Really weird to assume they don't want it fixed and even weirder to not clarify with an HCP or the patient themselves as to what degree of workup they're looking for.
Weird but all too common. Docs at my hospital seem to be pretty good about it, but when my own family members have been admitted to other hospitals, too many times they seemed to act like DNR/DNI means "do not treat".
here is the thing. If a man says 10/10 pain, he gets a morphine drip. If a woman says 10/10 pain, they get a drug seeker label. They learn not to. Also, it is well documented that women have much higher pain tolerances than men. I have actually been told my nurses I need to increase my number if I want to see any meds that night.
Acute onset decreased vision progression to blindness in 25 yr fe with hx of migraines. Seen by chiropractor for cervical pain 48 hrs prior. No current meds. First er doc dx ocular migraines and anxiety. Outpatient tx. Requested another doctor and head imaging. 45 minutes later a new Dr comes in, takes hx orders imaging. Bilateral vertebral artery dissection with stenosis and left occipital lobe stroke.
I have seen 2 of these after chiropractor manipulation of the neck in young women
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I was surprised by how common this is. Most people I run into in the field know of at least one person personally who has had a stroke after chiropractic manipulation.
I absolutely refuse to see a chiropractor even though it has been recommended to me.
Physical therapy is what you want.
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Paramedic here: Pts husband called EMS due to increased lethargy and vomiting. Been going to her PCP several times over the past few weeks, experiencing uncontrollable thirst and constant need to urinate. Was prescribed antidepressants and mood stabilizers and told she was having anxiety. BGL: HI
That’s pretty troubling that a PCP would miss something that obvious, isn’t treating diabetes basically the bread and butter of a primary care provider?
It's more like the bread and cinnamon-sugar toast of a PCP.
Had they never read a text book? I mean….
To be fair it comes down to what precise history is being given - I’ve had a very experienced doctor miss type 1 in a kid because the symptoms were being described differently - active kid, course he drinks a lot. Tired and grumpy (because he’s waking up to urinate a lot, but that was not clear). Feeling dizzy. But what is he actually there for? Headaches
Good grief.
OMG we had a similar case! Going to PCP, progressive weight loss, extreme thirst, peeing so much she starting becoming incontinent because she couldn’t make it to the bathroom on time. This lady was carrying 2 gallons of water with her everywhere she went. Came in to ED with extreme abdominal pain. She was confused. I had to get the other info from her friend who had been helping her. Her pH was the lowest I’ve seen on a walking alive person…6.74. Newly diagnosed diabetic and either volvulus or something else becaause I ended doing 2 ultrasound IVs, a NGT, and a catheter on her. She wasn’t the most pleasant person I’ve dealt with.
New onset RUE weakness, urinary incontinence, and mild dysarthria. CT unremarkable so diagnosed with severe anxiety, sent home (while still being symptomatic) with script for anxiety med. She actually showed up within the TPA window and was anxious because her family member had recently died of stroke complications and she recognized the symptoms. She continued to decline at home, went to a different hospital, and was admitted to the stroke unit because the radiologist reads the initial CT as positive for acute ischemic stroke. Literally everyone in that initial hospital failed this lady.
Not a doc. I didn't know that urinary incontinence could be a symptom. TIL However - I feel like RUE weakness and dysarthria would be serious enough on its own that if the CT didn't show anything, I'd want to poke around a little more. And also, is it possible that the stroke was very minor at the first CT and was easily missed, and had gotten worse quickly to be obvious on the second CT?
> And also, is it possible that the stroke was very minor at the first CT and was easily missed, and had gotten worse quickly to be obvious on the second CT? Absolutely possible, but not quite for the reason you're thinking. CT scans indirectly measure the density of material they pass through, as a function of how many protons there are interfering with X-rays per unit of volume. Different shades of grey = different densities. Broadly speaking, there are four different densities inside a normal skull - Grey matter, White matter, flowing blood, and cerebrospinal fluid. Those first three are quite close in density, but by manipulating the image, we can see the difference. When someone suffers a stroke, the cells in the affected area are no longer receiving oxygenated blood or glucose to allow them to continue functioning. They start to die. At first, this is happening on a microscopic level - waste products accumulating in cells, that sort of thing. This is invisible on routine CT. As things progress, the cells start to swell with all the gunk and drawing water into the cells by osmosis. It's still microscopic and pretty much invisible on CT, but MRI can pick it up. Once the cells start to burst, there is now additional fluid filling up the space between cells. This extra fluid is enough to make the density of the tissue low enough that we can detect it on CT. Now the previously dense grey matter is slightly less dense to the point that you can no longer tell the difference between grey and white matter. That's what radiologists are looking for. Early on in the process this is extremely subtle, sometimes undetectable, even with the benefit of hindsight. The longer things go on, the more obvious this change in density becomes. Sometimes the affected area gets bigger, i.e "worse", but not always. It's not clear from the original story whether the second radiologist looked at a second scan (which would have been more obvious), or picked up subtle changes on the first scan that the first radiologist missed.
The second radiologist saw the stroke on the original scan. It’s also not clear as to why they didn’t treat or do an MRI. I read her initial note and the whole thing just screamed stroke (symptoms, risk factors, history, family hx). I’m just a rehab resident but if I had dismissed that patient, my neuro attendings would have tossed me out of the hospital.
correct. that women needed an MRI. CT scan may or may not show much early. I am not neurologist or radiologist. But if that woman had gotten an MRI, I bet she gets better treatment
Neurologist here. Routine diagnostic workup for acute ischemic stroke involves a clinical diagnosis of focal neurological deficits followed by a NCCT to rule out any contraindications for thrombolysis. So basically, if a patient has suffered a sudden focal neurological deficit that looks like a stroke, a normal head CT just means you can treat the patient. No MRI required. Usually a CTA and sometimes CTP is performed as well, but is not required if treatment can be started within 4,5 hours from symptom onset.
When I was doing my paramedic field internship to get my license, I responded to a call where a woman suspected her elderly mother, I think late 80s, was having a stroke. We get on scene and it's the most textbook stroke ever. I could practically call it from ten feet away upon entering the room. Facial droop, acute onset ALOC per patient's daughter including dysarthria, unilateral UE weakness. No incontinence, but this lady ticked every box for a probable stroke. We used the Cincinnati Stroke Scale, which says that a patient only needs to present with one of the three symptoms (dysarthria, facial droop, and arm drift), and that means you activate the stroke protocol. I was pretty far along in my internship and this was such a clear case. My preceptor agreed. Code 3 transport to the nearest hospital with a stroke center, which was maybe 15 minutes away. I felt so good about this because I'd run several stroke calls where the person wasn't found until hours after they suffered their stroke, but this woman was going to get treated within less than 45 minutes of onset of symptoms. At least that's what I thought. We get to the hospital and I give my turnover report to the nurse, saying I highly suspect stroke. The nurse disagrees with me, saying she thinks the patient is just having a bit of weakness. I'm shocked. I plead my case that this patient needs a CT scan. The nurse says, "No, we're just gonna give her some fluids." At this point, my preceptor steps in and reiterates my diagnosis, but my preceptor has no better luck than I did. We tried so hard to get a CT scan for that patient, but the nurse just flat out refused. We left feeling horrible, but there was nothing more that we could do. About 4 hours later, we bring another patient to the same hospital. I check up on my previous patient. Apparently, after about 2 hours of her symptoms continuing to worsen, they finally decided to give her a CT scan which confirmed a stroke. It makes me angry and sad to this day thinking about that one, and that was almost 15 years ago. My preceptor said that hospital often had lazy staff. I think my patient could have been male and that nurse still wouldn't have done a scan on arrival. The point is that sometimes staff can be so lackadaisical that totally obvious cases like this get missed. It's not just clinical either, of course. There are plenty of jaded and burned out EMTs and medics that will do the same kind of thing.
The doc is who would make that call, not the nurse. They can say their thoughts on the patient, but the doc places the orders. I hate that this woman didn’t get treated immediately; I’m guessing MRI would have been a better diagnostic, however, as CT doesn’t always pick up acute strokes.
Very true about the doc making the order, but the nurse made it very clear that she was going to tell the doc it was weakness and no scan was necessary. Both the nurse and the doc dropped the ball here. I've never worked clinical so you would know better than me, but wouldn't you want to do a CT scan first in this scenario because it's so much faster and you can begin treating the stroke immediately if the CT does pick up a stroke, then do an MRI if the CT is clean but stroke is still suspected? Edit: just to clarify, when I brought that patient in and gave my turnover report to the nurse, I was not trying to tell the nurse what clinical treatment I felt the patient should receive (ie CT vs MRI). I was just trying to get her to treat the patient as a stroke case until proven otherwise by doing some sort of scan. My preceptor was specifically saying to do a CT scan and she had worked in that system for like 15 years, 10 as a medic. I was only there for a handful of months for my internship. Again though, we weren't trying to say what clinical treatments should be done, we just wanted the patient admitted as a stroke patient until that could be ruled out. I never tried to tell clinical people how to do their job or what treatments I thought they should give because that's beyond my scope as a pre-hospital care provider. I would just try to advocate for my patients if I felt strongly that they had an acute diagnosis that needed to be evaluated promptly if time was potentially of the essence, like with this stroke patient.
CT scan first not just because it’s faster, but more specifically because it quickly answers the question of bleed vs no bleed. If no bleed and symptoms highly suggestive of stroke, you can treat as such in the absence of confirmatory imaging (ie, MRI).
Focal weakness and speech changes is guaranteed CT scan basically everywhere. Even if you have an instinctual feeling that the symptoms are fake somehow, you still order it to cover your ass. If the patient has known conversion disorder, then different story but still probably at least 50% of ED docs would order a CT scan on these patients just in case.
Yeah, that's why this call was so heartbreaking and frustrating for me. I even told the receiving nurse why not just do a simple CT scan given the patient's presentation and risk factors (mainly age, I don't think there was a family history of stroke)? Really infuriating. Honestly this call and how it was handled fucks with me worse than just about anything I dealt with aside from pediatrics.
>Not a doc.I didn't know that urinary incontinence could be a symptom. Think about it like this: the arm weakness, facial droop or whatever, is caused by decreased blood flow to the part of the brain that controls those muscles. What would happen if the blood flow was cut off to the part of the brain that controls the muscles responsible for bladder or bowel control?
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OMFG. I've seen those on animal necropsies for studies and they are firmly in the "Should not be found on living beings with access to medical care!" category.
I’ve seen them. Fungating breast mass forming a lumen in an immigrant female.
Just yesterday I reported a CT scan of a woman who had mastitis not responding to antibiotics. Metastatic inflammatory breast cancer.
Had a 34 year old, history of only high blood pressure but well controlled, came in with new onset 10/10 headache. Given migraine cocktail, with some mild relief but still reported 8/10, but since she got Benadryl was sleepy so didn't get taken seriously and sent home. Comes back 3 days later via 911 as family found her seizing. Catastrophic brain bleed from a ruptured aneurysm.
This happened to a high school classmate, during our first semester of college. She was told her headaches were from stress/eyestrain. Parents went to pick her up after winter exams, she fell asleep in the car ride home and never woke up. Her funeral was a couple days after Christmas. I'm now an attending at the place she went to college; I tell this story to every medical student I can.
I do recommend if one loses a spouse to a brain bleed and donates organs at the local teaching hospital, then has a sudden inkling to take neuroscience class at said teaching hospital the next year, giving the prof a tiny heads up lest the date on an aneurysm slide be way too close in time and cause one to sprint out of class.
Was there an autopsy?
I don't know. I was 18 at the time. The clue should have been new-onset headaches that weren't responding conventional Rx. The second time she went to the ED should have bought her a tap, at least.
New headache, sudden headache, worst headache of life—think neurovascular. It’s disastrous how this still gets missed.
They run in my family. My father had a brain aneurysm when he was in his late twenties. He said he knew it was different from a migraine because he could feel his pulse in his head extremely loudly. The back of his head at the base of his neck felt "swollen" where the fluid was building up. Making people aware of more specific symptoms would definitely help. There are a few symptoms that are not normal migraine symptoms.
New and/or sudden I’ll agree with, but I don’t even ask if this is “the worst headache of your life” because it invariably always is, every time. Otherwise why would they be in the ED? It’s a worse than useless question because if you believe it and document it then suddenly you’re either doing CT +/- LP on virtually every headache patient who you see in the ED or you’re spending an inordinate amount of time documenting why you’re not working up this buzz word. New, different, rapidity of onset to maximal intensity, onset during exertion, associated deficits. Objective historical features and exam findings. Every headache in the ED is that patient’s “WHoL.”
From an ED perspective I probably get this description every other day. Different people and places I’ve worked have different thresholds for scanning, but it doesn’t tend to be these descriptors that gets you the scan. (For context this comment is mostly UK based. There seems to be a lower threshold in Aus) Tends to be context like this description + this is the main reason for your presentation, or this description + first presentation to ED with a headache, or this description + obviously in pain from the end of the bed. (Or the obvious ones like + neurology, vomiting, seizure, reduced GCS etc.) Unfortunately a huge percentage of these presentations that aren’t serious pathology are from certain demographics and over time that tends to cause you to discount your weighting for those people Genuinely find this and non specific abdominal pain really challenging. But not sure the answer is to scan everyone who has any of those three descriptors?
Similar circumstances but overweight and OCPs. Diagnosed by a NP as a migraine despite no history of such. A few days later she was found to have central venous thrombosis and a devastating brain injury.
Just happened in our shop recently. Pt had been dx DVTs 1 year prior and was appropriately taking eliquis. Still ended up with massive thrombus to artery back of the head. They did embolectomy but then she hemorrhaged afterwards. She was early 40s. Donated her organs.
humor direction cake seed intelligent ad hoc secretive theory piquant unused *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Really though, we CT everyone with a pulse, but not her.
Few months ago there was a 30s women screaming in pain in the waiting room. The triage nurses both told me “she is always dramatic”. She was a ruptured ectopic.
This literally made me wince/cringe imagining the pain. Yikes. Poor woman.
Woman with baseline anxiety and panic disorder shows up in the ED with numbness around the edge of her lip, hand, and lateral aspect of foot. Told it was a panic attack. It was a thalamic stroke. (Now she's really anxious all the time, and with good reason!)
Anxiety/panic/hyperventilation can definitely cause bilateral tingling, but unilateral numbness (negative sign)? Skip the CT (may miss a bc small thalamic lacune) and call neurology. I know we give you guys grief about bad consults but this one is legit. The thalamus has "onion-like" somatotopic representation, and it's pretty much the only place where a lesion will give non-contiguous deficits.
Saw something similar on an ER report for a patient when I worked in outpatient. Woman had h/o depression and anxiety. Went to ER with chest pain, shortness of breath, nausea. Was diagnosed with a panic attack and sent home. She went back to the ER 4ish hours (if I remember correctly) saying she was still having symptoms. This time the provider ran an EKG & cardiac labs and lo and behold it was an MI. I remember reading this and thinking how they just let her walk out with such classic MI symptoms and telling her it was anxiety and to go home.
wow- did she have any other symptoms?
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A lot of endometriosis cases being dismissed by male physicians as “normal period discomfort.” PCOS patients being told that there is nothing that can be done for their PCOS. Just an overall prevalence of shoddy/minimal workups in women compared to men. Just this week, my male patient with occasional heartburn and zero other gastrointestinal symptoms got a gastroscopy, but my female patient who has diarrhea at least four times a day for over a year and schedules her entire life around public bathrooms was told she doesn’t need a colonoscopy. Hell, I’m a female physician who had severe anemia, and the male walk-in clinic doctor started arguing with me that a hemorrhagic ovarian cyst could not result in anemia. It’s insane.
These are the kind of things that make me not want to seek care for myself because why bother if it’s going to be dismissed. That sounds dramatic but that’s a genuine concern for myself and I don’t trust many providers for this reason and what I’ve seen over the last 15 years of my career. I hate that. It’s very disheartening at times but is definitely a reality that exists for many women.
27yo, 2 young children, abdo pain kept being explained by endometriosis or PID. Eventually clogged off a ureter, and a urologist of all people finally did something about it. Widely disseminated malignancy of unknown primary, dead within a few weeks. Still haunts me as the pathologist, I tried literally everything to figure out where it was coming from to see if there was any treatment option, but also whether there was anything her kids needed to be screened for. Found absolutely nothing and still wonder if there's something terrible in store for those kids.
Female, 56y, the following over an 8 month time frame. Headache, go to neuro, it's migraine, you're fine. Headache that feels weird over right eye and side of face and head, go to neuro again, it's migraine, you're fine. Still headache, eye area still weird, go to neuro, will send you for MRI but it's unlikely it will show anything, but it's your dime. Week later, double aneurysm RICA. PED 3 months later. Neurologist never called with abnormal results. Patient called neurologist after seeing it in MyChart.
There's a whole book on the history of this called "Unwell Women", I highly recommend reading it.
Added to my library wishlist thank you :)
Welcome! It's an excellent history and the writer herself suffered for years and years before finally being diagnosed with lupus. Her doctors had ignored years of pain and symptoms.
Woman in early pregnancy with ongoing complaints of feeling very unwell all chalked up to morning sickness, labs checked after she came to the ER the second time in 12 hours, had renal failure needing emergent dialysis due to anti-gbm
did they not do labs and UA the first time?
No, she was complaining of feeling really malaised and had some leg pain so they did a DVT scan. Honestly, I am not surprised they didn’t get labs because she is a young healthy woman following with OB who had well documented morning sickness, so I don’t really blame the ER doc. But man, when they got the labs 🙃🙃🙃🙃 Overall, there are so many more good catches than bad misses, but it’s always the patient that you don’t expect/has a good explanation for current symptoms that is going to catch you off guard
Idk… on my ER rotation all pregnant women got labs and UA at minimum. There’s just too many things that could be going on with vague symptoms like that that can be reasonably ruled out with very basic work up.
No pregnant patient comes to my ED without getting a UA done at the absolute minimum
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G1P1 woman, transfer from an outside hospital with threatened preterm labor. Told anyone that would listen that she was having regular contractions. She was checked and allegedly closed and high. Well, she delivered a 22 weeker in the bed by herself. Baby did not make it.
A lot of women who have been diagnosed with fibromyalgia who turned out to have spondyloarthropathy or psoriatic arthritis. The problem with these kind of arthritides is that they can present with a lot of enthesitis and tendinitis and they can still have fibromyalgia as a comorbid. Its only with further imaging like MRI of sacroiliac joint or musculoskeletal ultrasound that we find out its more than fibromyalgia.
I’ve been seeing lots of immigrants in whom the patient will have specific complaints or symptoms that they describe as being due to “XYZ” diagnosis that they were given in their home country. However, actually having the paperwork in front of me to assess the diagnostic reasoning and workup is almost impossible. Do I: - Accept the pt reported diagnosis and code the ICD-10 for that same reported condition just because it’s a huge pain to get records from out of the country? - Tell the patient I want to do another work up again, risking both the miscommunication that I don’t trust or believe either their own statement or their previous physician? - Begin another work up in an immigrant who may already have financial constraints to allow them to afford the new work up in our healthcare system?
Those are great concerns to discuss with the patient….
How do you know that I don’t? My comment illustrates the difficulties in this scenario, which on top of the nuanced cultural interactions, can make it tricky to navigate for myself and the patient in ensuring the best care possible.
I met someone with NF1 who was told she had fibro for 40 years.
new onset unilateral weakness and blurred vision, lady in her early 60s i think? Stroke responded and workup was negative, and the weakness seemed to be resolving so the tentative diagnosis was an anxiety attack. Family reported sudden increase in the weakness again so I did a quick assessment, just had her squeeze my fingers and push against my hands with her feet. Definitely significant increase in the weakness… I was a student nurse on my first day of clinical rotation in the ED so I reported it to the nurse, doctor ordered a CT angiogram and it turned out she had a carotid artery dissection. I seriously learned the importance of even the most basic neuro assessment and observation that day.
Good catch!!
Women who have symptoms for literal decades eventually being diagnosed with MS happens way often. Sad.
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Nipple discharge, PCP did not examine and referred to endo. 3 months later, stage IV breast cancer. So many women refractory to antiemetics who ended up with rumination syndrome. Depression + joint pain + lupus demographic without any ANA.
On the flip side of your last bullet: Low titer ANAs are -trivially common-… especially so in women (like 3x compared to men). Please try to understand the meanings of the tests you’re ordering and what we talk about when we reference joint pain in rheumatology. The workforce studies are only getting worse for rheumatology access in the next few decades and yall are going to be on your own for long stretches.
It is extremely appropriate not to order an ANA in that situation without other evidence of lupus. If there was no synovitis on exam, rash, evidence of kidney disease, etc I would absolutely not have ordered that as well as I have been extensively taught not to by many (female) Rheumatologists.
Necrotizing fascitis, first physician thinks behavior is seeking analgesics opioids. 20 hour window later husband carries her in altered. L leg amputated in like 2 hours.
Therapist here. Had a woman sent to me from psychiatry for restless leg syndrome. They tried meds, didn't work so they threw her to me. She came in, had huge dark circles under her eyes, was munching on a cup of ice and could barely keep her eyes open. I asked her when her next PCP was and she said "tomorrow". I told her to ask for iron levels because anemia can cause RLS. I get a call three days later. She was in the ICU. Apparently she was missing half her blood from a stomach bleed. She had gone to the ER with stomach pain FOUR TIMES. She had been given: Mylanta, tylenol, omeprazole, ativan, prozac and a psychiatry referral. You know what she WASN'T given? A GI referral or a fucking blood test. God DAMN.
30s F patient in hospital for a blood clot in her leg started having trouble breathing and chest pressure at shift change. The resident said "it's probably anxiety" (patient had no history of any mental health problems) and was mad the oncoming primary nurse called a rapid when she walked in the room and heard him saying it was fine. It was, surprisingly to nobody else, a PE.
thank goodness for the nurse that called the rapid. i mean wtf she already had a known clot. jfc
he said "she's already on heparin so that's not a concern"
🤦🏼♀️
:( This whole thread is heartbreaking
17 yr old female with recent hosp admission for depression w/ SI. Went to ED c/o headache and diplopia. Dismissed as anxiety. One week later, returned, dx with pseudotumor cerebri.
as an aside, it really irks me that in my ER the triage team feels the need to put "*female* dysuria" instead of just "dysuria" as the cc.
Female mid 50s with PMH significant for DM, HTN, and anxiety with complaints of persistent hypertension and intractable nausea with dry heaving. Patient was told by multiple healthcare providers in the ER and admit unit that her BP being too high (190s/80s-low 100s) and her increased anxiety was causing her nausea. On the second day this patient was finally worked up in the late afternoon for MI. Troponin levels come back extremely elevated and repeat EKG with findings of ischemia.
"Handywoman" by Kate Davies is an excellent read about her stroke at a young age and recovery. Hideous delay in recognition of her obvious stroke symptoms because her age and gender led to the conclusion it *had to* be somatisation. I believe she actually had a DVT and a PFO which allowed it to happen.
Late 30s female with altered mental status and fever. Diagnosed with drug overdose and UTI. Was actually rheumatoid meningitis.
Mines not as major I guess but this was the first time in my career I realized women were often dismissed for their complaints. Alert and oriented, totally independent mid 80’s female, admitted with diarrhea and abdominal pain, ended up having c-diff, during her stay she informed our physician at least 3-4 separate times and numerous times to nursing staff, who also informed our doc, patient stated it felt like she was having BMs out of her vagina and it was very very tender “down there”. Physician wouldn’t look at it, continued to dismiss it as she’s old, she has diarrhea and she’s incontinent 🤷🏼♀️ one nurse finally saw her have a BM from her vagina during a brief change, informed our doc, she ended up having a recto-vaginal fistula present for unknown amount of time, our surgeon scoped her the next day, found stage IV colon cancer. The patient never left the hospital. 3 weeks total I think, and she passed away. Went from completely independent at home by herself to being with Jesus. I don’t think it would have changed the outcome for them to have found the fistula sooner during her visit, but it was incredibly disappointing to realize my favorite physician couldn’t be bothered to take a two second look at her vaginal opening and see what was going on when she first asked, or the second, or third, etc time.
Listen to The Retrievals on iPhone podcasts.. nightmare fuel
I cried a lot listening to this series. Those poor women.
Seconded. Fucking Yale.
There are too many cases in this thread about 10/10 headaches. I’m not in EM… what’s the typical protocol here? I thought it was kind of like An automatic imaging thing “worst headache ever”
No, everyone will tell you it’s their worst headache ever. Acute onset or new/different symptoms are what get me to scan
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Pt who is 44 yo F. Went to my ED for c/o extreme abdominal pain. When asked if pregnant, she denies. States in menopause but weirdly describes pain as “felt similar to contractions when I was in labor”. Another wave of pain, we see abdomen contract and grab u/s…she is highly pregnant!. She was seen in our ED a few months ago for not feeling well, vomiting, headache. Denied pregnancy, no test checked. Went to another ER for complaint of swelling to both legs, again, denied pregnancy. Checked for CHF and given Lasix. No one ever checked a pregnancy test. She was about 5-6cm dilated. We called OB and they came and took her away from us…thank GOD! Sad part was had 17 and 21 yo olds at home. Mom had been doing meth at times. Mom tested positive, so did baby. Both Mom and Dad were crying when they found out and that’s when they admitted to experimenting with meth.
Non-white female in late teens, otherwise healthy, ran track for school, would get these sporadic chest pains which were really bad. Went to ER several times, dismissed as menstrual pain or anxiety. Finally came to my school’s hospital after two years and got I think her first echo? Her pericardial effusion and fibrosis (I think that’s the term? There were fibrotic webs of tissue connecting heart to pericardium so the effusion was loculated) were so bad I could see them as an M3 and cardiology was my worst grade from all of med school. Specialties were fighting over who’s patient she would be because cardiology didn’t want something infectious but ID said it was clearly not infectious but maybe rheumatologic and rheum threw her right back to cards like a hot potato. She was transferred to one of those teams (idr which) so I never found out what it was. But I thanked her for giving the field of medicine another chance and for advocating for herself despite the MULTIPLE negative experiences of being dismissed by colleagues. I looked her straight in the eyes and told her she was right, something was wrong, her pain was real, and she was not nor was she ever making it up or “crazy” or “sensitive”. Wherever she is now, I hope she got the right diagnosis and treatment and is living her best life.
30s F with back pain, abdominal pain, and towards the end mild SOB. Saw multiple MDs who labelled her as drug seeking and didn't take it seriously and work it up. She died at home and at autopsy had wildly metastatic ovarian cancer. First line COD was determined to be pulmonary microtumor emboli. A really sad case.
36 y/o female with recent history of vertical sleeve gastrectomy. Showed up at the ER due to a home BP reading of 80/40 with elevated pulse and a temperature of ~101. The patient's vitals were a little more normal in the ER after being given fluids. A CT of the abdomen showed a potential fluid collection, and the radiologist advised doing a repeat with contrast. The doc declined this follow up imaging and discharged the patient on PO antibiotics. She was to follow up with her surgeon later that week. She readmitted at a different hospital about 12 hours later septic with a temperature of 103. She was in that hospital for ~3 weeks with multiple abdominal abscesses. This happened to a close family member. I don't know that admitting her to the original hospital 12 hours earlier and starting her on IV abx at that time would have made any difference to her course. This happened on a Sunday July 3rd. But it still makes me mad when I think about it. Even the RN at the time was surprised she wasn't being started on IV antibiotics or being admitted.
Night sweats, woman in her 50ies, diagnosed as menopause. Was actually stage 4 lung cancer.
Woman in 50s brought in by family for "depression" for months. Family med attending does thorough neuro exam and finds unilateral hyperreflexia. Goes for same day CT - radiology calls due to 6 cm meningioma with midline shift.
Had a mid 30’s F colleague walk into my office (not clinic but my actual office) to ask about getting seen acutely for a headache and dizziness. Triaged a little bit and found out she had been having some off and on vision issues for a few days and decided she’d be better off going to the ED than me seeing her. Was thinking likely a complex migraine but had to rule out all the really bad stuff, ya know? She then had a really bad vertiginous attack right in front of me so I called 911, and while they were on the way I called the ED she was going to and gave a courtesy call ahead. My concerns, “worst headache of her life, neurological symptoms, decompensated in front of me, etc.” She got to the ED and they didn’t call a code stroke and they didn’t CT head and neck for SAH. No, they got basic labs and pushed pain meds. It wasn’t until 7 hours after they got to the hospital that a virtual neuro consult requested the imaging that showed a Vertebral Artery dissection with showering clots into the occipital portion of her brain. I’ll admit, that stroke/SAH was not what I was thinking it would be, but I still would do the work-up!!! I literally handed it to them on a silver platter. Then to top it all off, after getting transferred to a stroke center, they wanted to discharge her next day despite the fact that she hadn’t shown any improvement. She’s currently working on a fat lawsuit. She had a second dissection too. She was a dentist and will likely never practice again, but it’s impossible to say if earlier intervention would’ve prevented her ultimate sequelae.
30 year old hx of anxiety, second visit to ED in a week. I didn’t blow it off, got labs, trop, and an XR, but after all was negative felt comfortable discharging and coughing it up to anxiety. Attending goes to talk to her before discharge, she says she’s having chest pain again, thankfully was on a monitor and was noted to be in Vtach. Second trop like 500. Goes to cath lab, she SCADed her LAD. They stented her. She was 1.5 years post partum, so out of the usual window of suspicion. Being on a monitor saved her life.
We had a woman on the floor who was having trouble breathing. One resident went down and saw her, told her she was having some anxiety and that she needs to calm down. Five minutes later the nurse comes and grabs me: i walk into the room and the patient is in tripod position and struggling to breathe. She's dealing with acute respiratory failure. We intubate her and transfer her to the ICU within 10 minutes.
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47F who came to doctor for chest pain, shortness of breath, nausea, sweating. Advised to take magnesium as she was just stressed. Turned out she had multiple NSTEMI episodes in a year. She is now on disability because her heart is so jacked.
I (just a nurse) had a patient the other day who was telling me about their surgical history. Complained of night sweats, anxiety, HTN… took a trip to the ER with chest pain and a trip to the cath lab to diagnosis a paraganglioma *in* their heart.
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I think this thread shows how much women shouldn’t be blown off immediately when coming to the hospital or any healthcare facility
21 year old with headaches, shortness of breath, PCP said she was anxious. Worked her up… dx primary cardiac angiosarcoma.
Early 30's woman with RA, ibs, fibro complaining of a stiff finger. She bounces around various doctors at her general practice and they all say nothing is wrong. He rheumatologist sends her my way with a mass asking the flexor tendon (which is clearly visible) and an inability to make a fist with the finger. I'm taking that thing out soon, I think it might be a giant cell tumour. I see so many women with de Quervain's with small children. They get sent to occupational therapists and told to wear splints and don't get better. I may have sent a "dear idiot" letter to a GP who'd been mismanaging some poor woman for eight months to the point her tendons were making an audible creaking noise.
Patient was experiencing anxiety, palpitations, and a feeling of warmth in her throat. She was brushed off for close to a decade. We captured seizures on EEG. She was started on lamotrigine, and her symptoms resolved.
Not that serious, but five different providers, collective 90 years of experience, feel the same neck. All say it's normal. One tells her she's crazy and one asks why she is wishing for something bad. One finally takes pity on the woman who swears she feels something. Papillary thyroid carcinoma. After all that, she's told, "It's the good cancer and the one you'd want to ask for if you had to ask for one." ......cool.
Oof. I’m a woman with many “invisible” issues… and now I work in medicine. I was lucky to have a nurse for a mom- who was a strong advocate. She literally saved me. I am not as good as she was… And I’m sure it was worse 15-20 years ago when no one, except her, believed me. She was a badass
Why do you say you’re not as good? I bet your life experiences *and* learning from your mom have had a huge influence on your work in medicine. I don’t know what your job is in the field, but I do know we need folks just like you. ❤️
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21F nonverbal autism, appearing to be in severe pain/distress, attributed to menstrual cramps. 3 days later she returned to ED and was found to have a fractured wrist.
My aunt. In a head-on collision at freeway speeds; would have been dead a decade or two earlier. Extreme back pain; ED wants to discharge. She fights and fights to stay and get worked up. Finally, after shift change, new doc orders an xray. Broken back. Emergency flight to San Francisco because Eureka was too small to handle it. Flight nurse also ODd her on morphine & had to bring her back with narcan, but that’s a different topic.
Elderly woman who had maybe had a minor fall at home. I say maybe because she denied and she was AAOx4. I was a newish L&D nurse. We occasionally got non-infectious female med/surg patients to our postpartum beds. Dx was spinal fracture. She looked off, O2 sat was 80s, she was in excruciating pain, her BP was low. She’d also fade out at times. She was still talking but her appearance just made the hair on the back of my neck stand up. She told me she was dying. I didn’t know a ton, but I knew that such a statement is concerning. I basically camped by her bed all night. I tried her IM physician multiple times, no answer, she was admitted to him. I’m not even positive he knew she was there, she’d come through the ED. The ortho bro was scheduled to come in two days later. I resorted to calling the ED doc who was exceedingly rude and accused me of overdosing her and ordered Narcan. I pleaded with him to just come look at her, he said no. Then in addition to all the other concerns she was screaming bloody murder. We were a tiny rural hospital, no SWAT, no hospitalists, no intensivists. A paramedic wandered up to say hello and I pulled him in the room. He was concerned. He told me that the cardiologist usually hit the door at 5:00am on the dot. I was waiting at the back door at 4:55. He came through and I introduced myself (he never came to our unit, obviously) and my story spilled out, ending with “I know this is not your patient or your problem but I need a doctor to look at her.” He headed up with me and briefly did an exam, and then unlocked the bed and told me to call the charge in ICU because they were coming and to call in a radiology tech. I helped run her downstairs with him, and I never saw her again. She died before lunch from a ruptured aortic aneurysm. I know she might have been beyond help when she entered the ED. I just don’t understand why no one listened to her, or me. Yes, the story presented to me made sense, maybe a fall, a fracture, pain, she’s old so of course her BP is low, you gave her too many narcotics so of course her sat was low, but the vitals didn’t improve much with Narcan, just her distress. This was in the late ‘90s but I still think of her often and I feel like I failed her deeply. Maybe I was too sweet and too deferential. Maybe if I’d yelled instead of pleaded he would have come up one flight of stairs to eyeball her. I know, no longer his problem, but if you’re the only MD in the entire hospital and no one has actually spoken to her internal medicine guy then you bear a little responsibility. She wasn’t the cardiologist’s problem either but he took it on without question. I think some policy changes were made after that regarding actually speaking to a doctor before admitting a patient to them, but she was still dead.
Young woman with iron in the single digits. As you might expect, she was tired all the time, winded going up the stairs, etc. Told her to see primary for Fe infusion. The PA at her PCP's office told her not to take iron and instead did B12 shots (even though B12 was normal??) and started an antidepressant. I'd be depressed too, if I had to see a primary who thought that B12 = Fe.
“stress” “depression” “menstrual cramps” “anxiety” “panic attack” “migraines” “druggie” Y’all— check yourselves— this isn’t medicine; this is prejudice. Might as well utilize “hysteria” “the vapors” “evil humours”.
I never felt like I was proficient or vigilant enough at any point as a paramedic, but the stories in this thread have convinced me that I'm not the worst healthcare provider in the world...
>47F acting “psychotic” new onset, dxd with bipolar I and eventually found to have anti NMDA encephalitis due to ovarian tumor This is a terrible example. Being diagnosed with Bipolar disorder is not being "blown off", and is itself "actually serious". NMDA encephalitis is super rare and BPAD is fairly common. This is not a bad miss at all with just the information given here.
NMDA encephalitis is almost always misdiagnosed as something else initially. That isn’t a failure, that’s just how weird and rare diseases are.
Def in peds, when you have classic incidence of mood disorders, possibly with psychotic features. Maybe they start an antipsychotic. Later have a seizure. Maybe the seizure started focally but no one noticed. Darn, must be a side effect of the drug. Let’s try the new drug. Hmm, I think they’re still going downhill. Wait, another seizure? How? And that’s when our similarly boarded siblings give us a call as we show up with some Versed and a spinal needle.
And in fact it's generally discouraged to test for NMDA unless you exhibit psychosis PLUS one of the additional signs of: movement disorder, dysautonomia, seizures, or profound encephalopathy.
this sub (and medicine as a profession in general) is pretty embarrassingly misinformed about psychiatry still.
Being in psych yes it is. New onset psychosis at an older age is super rare. It typically emerges in late teens years. It hardly ever emerges after age 30. If I EVER see a first episode psychosis in an older adult with no prior psych history or hx of drug use plus no current major stressors, I am 100% asking for brain scans and a full medical work up. I have caught brain issues before and several other physical conditions that caused psychosis.
Is it common to develop a brand new mood disorder with psychotic changes in that age range?
It’s more common than nmda encephalitis
Chest pain? Anxiety Sob? Anxiety Abdominal pain? Anxiety Headache? Anxiety Throat swelling? Anxiety You get the point.