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chiaroscuro27

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  1. 58 yo male presented yesterday to my ED. My attending was on the floor, so I pulled the chart and read the triage note: "facial twitching for three days." The nurse told me it was likely bell's palsy. I went in to see and interview the patient. Very pleasant man with no obvious deformities or twitching at first glance, but the more he spoke the more it became apparent. His story: 3 day history of left-sided facial twitching. It began with his eye, then moved down to the corner of his mouth. Much better since yesterday, but he notices he has trouble chewing on the left side and when he drinks water he drools out of the left side of the mouth. He has no difficulty swallowing, though. Denies any other areas that twitch. Denies weakness in the arms and legs. No recent illnesses, no recent travel out of the state or country. No unfamiliar water or food sources. No coughs, sniffles, sore throat, abdominal pain, etc. Nothing. Has been feeling fine up until three days ago. I do a neuro exam: facial sensation is intact, EOMI, PEERLA, TM's are clear but I see what appear to be bubbles behind the TM's bilaterally. No pain when I move the tragus or pinna. Mucous membranes moist. Something is wrong with CN VII: his smile is crooked, he can't puff out the cheeks, the left eyebrow droops when he attempts to raise them, and I can open his left eye easily but not the right eye. Peripheral motor strength is equal. Pronator and romberg are normal. Gait is normal. Speech is excellent. Patient is alert and oriented x 3. I ask specifically about this happening before and he finally admits to it happening one month prior. The twitching lasted less than five minutes and never came back until 3 days ago. I ask specifically about headaches. His reply: "Now that you mention it I have had this vague, nagging HA on the right side of my head behind my eye." That was enough to scare the crap out of me. I ordered a CT of the head, and presented the case to my attending while waiting for the report. The report came via a phone call from the radiologist: 4.4 x 3.5 cm mass in the right frontal lobe. Consider primary lymphoma, or metastatic neoplastic process. Follow up with MRI w/wo contrast. That was the hardest news I've had to give a patient to date. I transferred him to a tertiary center. Pearls for new grads: 1. It bears repeating: respect the nurses, but don't hang your hat on a word they say. Sure bell's palsy was on my Ddx, but I'm learning more and more how much tunnel vision can get you into big, big trouble. You have license to diagnose, they don't. Try to assess each patient as if you know absolutely nothing about them. 2. When in doubt, always return to the HPI and the ROS. Nine times out of ten it will give you answers to questions you may not have thought to ask otherwise. 3. Trust your gut. Thoughts cross your mind for a reason. If you think about doing something, go ahead and do it. 4. Know your limitations. I work at a small, rural hospital with hardly any back-up. We transfer patients to tertiary centers all the time. There are some attendings who would have sat on this guy and wasted a lot of time. Advocate for the patient and get them to the folks who can help them.
  2. Yes browndog, so true. I am getting a lot more comfortable each day, but the fear factor is still there. One part of the job that I struggle with, especially in a rural town where everyone knows everyone, is allowing the nursing staff to sway my clinical decision-making because they have a history with my patient. There have been a lot of close calls because I considered not calling in ultrasound late at night for that suspected gallbladder issue, or not getting the stone study on a known drug seeker who really looked like they were in pain. So yes, I realize more every day the huge amount of responsibility I have and how easy it is to miss things. I'm glad, though, that I chose the ED! I was so close to taking a 9-5 transplant surgery position. The ED gives me the challenge I want, but also allows me to live my life and forget about work once I clock out.
  3. PA for the win indeed! Great article. Pertussis was on my Ddx after the first few paragraphs.
  4. There's nothing to do but move on and hope for the best. I'm sure you did much better than you think. Best of luck to you, and don't be so hard on yourself!
  5. Yeah...let's not. I'd hate to see someone's feelings get hurt. I am currently precepting an NP student. I cannot put into words how floored I am at the lack of knowledge this student has. Clinical year is all about building upon a medical foundation, getting your hands dirty and applying the medicine you've learned. With this student, there is no medical foundation to build upon. Classes of drugs, how they work, building differentials, suturing, etc. How can you build a differential list if you don't know the clinical findings of common diseases? I don't expect the student to know everything, but for goodness sake give me something to work with. I am grateful every day of my life that I chose PA! The AAPA has never received a red cent from me. I'm seriously considering getting involved with PAFT. We need some serious intervention NOW.
  6. Never heard of that method, Emed. Thanks. We don't have MRI available 24/7 but that's something to keep in the back pocket.
  7. I've come across four or five studies totaling 1000 participants -adults and children alike- that demonstrate both oral and iv contrast are not necessary. Sure, it's helpful to use it to rule out other intra-abdominal pathology. In the ED with true emergency cases, I would question the need for oral contrast altogether given transit time. I'm inclined to agree with you TruAnomaly that radiologists are not seeing this literature. Perhaps this is just one of those things that will take some time to catch on. Contrast is indeed helpful, but why use it if the literature says otherwise? Aren't we supposed to be practicing evidence-based medicine and doing patients no harm? Thanks for entertaining questions from a greenie.
  8. Had an 18 yo female come in with periumbilical pain, positive McBurney's point, nausea and anorexia last night. She didn't look ill, but everything was pointing to appendicitis. Ultrasound was gone for the day (isn't that always the way it works out), so I played with the idea of a CT scan of the belly and pelvis. Got her labs back...nada. Discussed it briefly with the attending and told the nurse to order a non-contrasted CT of the abdomen and pelvis. The attending looked puzzled and asked why I wasn't giving IV contrast for an appendicitis rule out. Good question. I know this is a controversial topic, but the literature that I've seen says that with a 96% and 98% sensitivity and specificity, non-contrasted CT scans for the purpose of ruling out appendicitis are as good or better than contrasted studies. I shared this with the attending. He was so intrigued he made calls to other colleagues, including a radiologist. Most of them had heard of this practice but admitted that most clinicians in the ED use IV contrast for appendicitis, and some use both oral and IV. Thoughts?
  9. Amazing shift. Terrifying, but amazing!
  10. No problem. I'm happy to do it. I'm 2 months into the job. You can't imagine how huge the learning curve is. I'm as green as they come, but here's some food for thought: - always put horses before zebras. - be aware of how common diseases present, but don't necessarily rule diseases out if the presentation is atypical. - kids and the elderly require extra attention to detail because the presentation can be so different from what you'd expect. - always trust your gut, no matter what the nurses or other ancillary staff think/say/do. - YOU as a non-physician provider must assume responsibility for all the choices you make on the patient's behalf. Don't take this responsibility lightly. - identify early on who the "teachers" are at your hospital/office. I'm lucky to have lots of physician teachers at my beck and call. I ask lots of questions and I learn so much from them and the nurses every day. Don't be too proud to ask questions, and don't be afraid to look stupid every once in a while. So, after we got the confirmation that it was indeed pancreatitis I immediately made arrangements for transfer to the children's hospital in the big city. I had a lovely chat with the pediatric GI folks there who were happy to take the patient in. Kept the girl NPO, kept the fluids going, and provided her some pain medication although she never once asked for it. She was a real trooper! Her amylase was 2991 and her lipase was 2665. Impressive, indeed! This was the first peds case I did on my own from start to finish. I'm just happy it turned out the way it did. It could have easily gone another way. More cases coming soon.
  11. Great thought, sailordec. I'll also add Mononucleosis to the list. I've seen Mono in kids with abdominal pain and no exudative tonsillitis. I ordered a Monospot and it came back negative. So, ultrasound is out of the question due to time constraints. Your patient is looking sicker every minute and you decide to proceed with CT scan of the abdomen and pelvis with IV contrast. The final report reads as follows: "Acute inflammation of the pancreas, with inflammation of the second portion of the duodenum secondary to pancreatitis. No stones, no pseudocysts, or necrosis." The gallbladder, appendix, spleen, pelvic organs and bowel were all visualized and read as normal, with the exception of the duodenum. Do you still want to call surgery? What tests could you have ordered to rule pancreatitis in or out? What interventions do you make now? Remember, you're in the boonies.
  12. At our institution that ALP was flagged as an abnormal level. I wasn't too impressed with it in light of the other LFT's, but there is something to consider here. Think about the presentation so far. This girl was fine the night before. No recent illnesses, ate breakfast and was out with the family when all of a sudden this stomach pain began. It has gotten worse since she presented to the ED and continues to get worse and worse. And now she's vomiting. So yes, the ALP may be slightly elevated now, but as she is showing us, things can change in the blink of an eye.
  13. Done! The nurses at your hospital don't like sticking kids and they give you hell for it if they don't think its warranted. Oh well, she's your patient and your clinical suspicion and the fact that she's vomiting yet again has bought her a line in the right AC some fluids. NPO...done. The rural ED has its own unique set of challenges. No specialists, very little ancillary staff on the weekends, no emergency dialysis, no MRI, and no US unless it is emergent. You have the nurses call to see if US can come in. They tell you it will be more than an hour before anyone can show up. Let's hold off on consultations until I get more feedback from other players. Comb through the Ddx. Have you done all the simple, easy things to rule them in or out?
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