primadonna22274 Posted August 1, 2006 Share Posted August 1, 2006 Sean, she came to you because her son & daughter-in-law who know you and trust you brought her to you. You did what you could for her and sent her on. God bless her. HERE IS A GOOD ONE GUYS....I caught this at an Urgent Care Center today. 81 y/o white female presents with Nausea and vommiting x 2 days. She denies any Diarrhea, flatus fever or appetite for 4 days. States her belly has relly began to hurt over the last 4 hours. She has a pass medical history of HTN, Hypothyroid and GERD. No surgical Hx. Lives with son and wife who are known to me and are good caretakers. He is a Rabbi. she a school teacher. Exam found an ill appearing 81 y/o woman with poor skin turger, dry mucous membranes. HEENT Dry tongue, otherwise nl CV tachy but regular, no MRG Lungs: CTA no resp distress Abd: large distention of lower Abd. Gaurding, TTP absent Bowel sounds. Remainder of exam Nl. CBC, CMP could not get results till tomorow so i did not bother I assumer I was sending her to Hospital for admission to R/O SBO vs Bowel Ischemia KUB shows large abnormality in pelvis CT with minimal PO contrast ( have mobile scanner onsite) and rectal contrast ( did not use IV b/c of no BUN or Creat in an 81 y/o) results: a 9.5 CM pancreatic MAss in the Head and proximal Body with a LARGE gallbladder that extends into the PELVIS. I HAD NEVER SEEN A GB THIS LARGE BEFORE!!!!!!! Surgeon called, she was admitted and Perc Drainage of tumor/GB by IR completed.....METS CA with Stricture. POOR LADY ( WHY DID SHE COME TO AN URGENT CARE WITH THIS?) Quote Link to comment Share on other sites More sharing options...
paintx Posted August 2, 2006 Share Posted August 2, 2006 I do get tired of the fast track mis-triage. It happens way too often. It would be really easy to go along with the triage decision and focus only the chief complaint w/o asking the right questions and doing a thorough exam. One such pt was 24 y/o male no previous med hx with nontraumatic RLE pain and rash on foot. Sudden onset of pain woke him from sleep 5 days prior. Pain worsened with passive extension/flexion of foot and palpation over the anterior tibialis muscle. The rash was actually purple mottling of the skin over the entire foot. No cap refill in great toe. No dopplerable DP pulse, barely dopplerable PT pulse. ABI revealed no pressure detectable in great toe with evidence of acute arterial occlusion at the popliteal artery. Arteriogram confirmed the diagnosis. Poor guy. Not sure of the outcome. Quote Link to comment Share on other sites More sharing options...
surgpa7714 Posted August 2, 2006 Share Posted August 2, 2006 One of my favorite recent triage patients presented with "cough" times several days. BP was 220/130!!! Of course he was sent back to me in the "fast track". I had no IV's, no monitoring equipment, no meds....nothing! I put him on the exam table....went through the h&p, treated with a beta blocker over 2 hours with VS q 5 minutes. Amazing how his cough went away after his BP came down to 120's. After I finished up on this guy, I went up to the triage nurse to suggest this was a totally inappropriate push back to my area where I had very little to work with. She told me the ER doc was up front changing the triage from "ER" to "Fast track" so he could sleep longer. Needless to say, I lit him up about endangering the patients this way. I'm not sure about being "invited" back for some weekend shifts, but he will not be sending anymore of those pts. to me in that area of the hospital. Mike Quote Link to comment Share on other sites More sharing options...
caldje Posted August 2, 2006 Share Posted August 2, 2006 I do get tired of the fast track mis-triage. It happens way too often. It would be really easy to go along with the triage decision and focus only the chief complaint w/o asking the right questions and doing a thorough exam. One such pt was 24 y/o male no previous med hx with nontraumatic RLE pain and rash on foot. Sudden onset of pain woke him from sleep 5 days prior. Pain worsened with passive extension/flexion of foot and palpation over the anterior tibialis muscle. The rash was actually purple mottling of the skin over the entire foot. No cap refill in great toe. No dopplerable DP pulse, barely dopplerable PT pulse. ABI revealed no pressure detectable in great toe with evidence of acute arterial occlusion at the popliteal artery. Arteriogram confirmed the diagnosis. Poor guy. Not sure of the outcome. thats interesting. Did he have any history? Seems strange for a 24yr to have a thrombus/embolus... Any idea/suggestion as to the underlying cause? chris Quote Link to comment Share on other sites More sharing options...
paintx Posted August 2, 2006 Share Posted August 2, 2006 Neg PMH, non smoker as I recall. Will try to recall his name and review his admission summary and give f/u. Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted August 2, 2006 Share Posted August 2, 2006 Last case reminds me very much of a 21 y/o lady, PMH neg, overwt, 1-1 1/2 ppd smoker for 2 years, encountered in my first year of practice. Another PA saw her on my day off but filled me in: c/o acute onset <1 day of severe pain in one of her toes (don't recall which one) which brought her in to outpatient family practice. No hx trauma. PA does the exam: foot is mottled, cool, toe is purple, no palpable pulses. Sends her for venous doppler STAT: very little blood flow to the toe (don't remember exactly where the occlusion was). She goes on to the vascular surgeon tout suite who stabilizes her for the moment (angio? I think) and sends her on to the med school. Final dx: Buerger's disease, also called thromboangiitis obliterans, a potentially devastating condition. She stopped smoking THAT DAY when threatened with progressive amputations. I think she managed to keep most of that toe in fact and was still not smoking when I left two years later. L. Quote Link to comment Share on other sites More sharing options...
medic25 Posted November 28, 2006 Share Posted November 28, 2006 My favorite mis-triages belonged to a couple of colleagues. Male in his 40's, triaged as "s/p motor vehicle collision, c/o neck pain". Walked back to urgent care by hospital PD because he was being "a jerk", per the triage nurse. Within 10 minutes, patient is moved from urgent care to the trauma room, intubated, with a head bleed and C2 fracture. Another buddy had a "finger laceration". He asked the patient if he was hurt anywhere else; patient opens his shirt to reveal the stab wound to the chest! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 28, 2006 Author Moderator Share Posted November 28, 2006 Earlier This Week: Thyroid Storm In Fast Track...but It Gets Worse....pt Had Hx Of Same And Told Triage Nurse That's What He Thought It Was....and He Was Right.....i Asked The Triage Nurse Why They Did This And They Said" What's Thyroid Storm?" !@#$%^&* Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted November 28, 2006 Share Posted November 28, 2006 :eek: Gosh, the palpitations, hypertension, tachycardia, profuse sweating, acutely anxious patient presentation didn't clue her in? Earlier This Week:Thyroid Storm In Fast Track...but It Gets Worse....pt Had Hx Of Same And Told Triage Nurse That's What He Thought It Was....and He Was Right.....i Asked The Triage Nurse Why They Did This And They Said" What's Thyroid Storm?" !@#$%^&* Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted November 28, 2006 Share Posted November 28, 2006 This one didn't happen to me but to my former medic partner's best friend... A drunken college boy shows up with his drunk girlfriend & other drunken buddies, c/o "stubbed toe." Entire foot is wrapped with enough gauze for mummification w/o breakthrough bleeding, so nurse doesn't de-mummify the toe. The kids are generally freaking out about the boy's toe, "it's so bad!'... "he needs help, now!"... "why aren't you helping him?!" Finally the boy is brought to a room to sleep off the party... and his friends are told they need to leave the waiting room because "it's going to take a while to fix this, it's just so bad..." :D Finally the boy wakes up and is howling in pain. Asked what happened, he confirms that he stubbed his toe. Told to keep quiet and someone would come see him when they could. More important pts to take care of... Finally the doc goes in and unwraps the toe. The boy had "stubbed" his great toe so badly that he obliterated the distal phalange & all the soft tissue around it. Distal toe couldn't be repaired... Moral of that one... look at the stubbed toe! :p Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 28, 2006 Author Moderator Share Posted November 28, 2006 :eek: Gosh, the palpitations, hypertension, tachycardia, profuse sweating, acutely anxious patient presentation didn't clue her in? she didn't know what it was. hard to recognize something you have no frame of reference for. Quote Link to comment Share on other sites More sharing options...
PACMattM Posted December 31, 2006 Share Posted December 31, 2006 Last month, 16 year old walked in with mother because he had fallen down and bumped his head. Nurse forgot to ask about LOC. I was working Peds fasttrack and when I palpated the step off of his lambdoid suture and got the "3 minute unconscious" history, I knew I was screwed. I trotted to order the head and c-spine CT and when I got back he was posturing and had fixed right gaze. He was still in his c-collar that I had placed on him and he was supine. I just kicked the brake off the bed and started running him toward the main side of the ED. He started vomiting along the way and seizing and I was screaming ahead to get the RSI kit and to open the airway cart. We got him sedated, paralyzed, and intubated in about 3 minutes and had him in the scanner to find his bleed. And then of course my favorite is the febrile infant who is "sleeping" but actually seizing. No wonder I couldn't wake him up! Poor kid sat in the fast track room for like 5 minutes before I looked in and saw him sleeping in a seriously rigid manner but basically all out of ATP to generate any further movement. Yikes! I hate fast track unless I am triaging, and I can't be in two places at once! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 16, 2007 Author Moderator Share Posted February 16, 2007 triage note: "anxious female" 60 yr old very anxious female complaining of n/v and diffuse abd pain x 1 hr no diarrhea or fever. nonsmoker, social drinker s/p chole vs stable/afebrile very anxious pt hyperventilating and holding abd rocking back and forth and retching ativan/reglan/benadryl iv required in order to get any hx from pt. after pts nausea and anxiety under control exam shows diffuse abd tenderness with rebound. labs(cbc, chem panel, lft's, lipase, ua) unremarkable ct scan 1.5 cm appendix "near to rupture" per rads transfered to dept of surgery moral of the story: just because someone is crazy does not exclude them from also being sick.... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 8, 2007 Author Moderator Share Posted March 8, 2007 30 yr old "developmentally delayed( maybe functions at level of 5-6 yr old)" male pt with c/o of neck pain after fall. triaged low acuity despite ems arrival in full c-spine precautions. fell from last step(maybe 1 foot) of a set of stairs landing on back. c/o 1/10 neck pain without radiation. no c/o neuro deficits. no head injury or loss of consciousness, no n/v. exam- stable vs, nad ms: collar removed to examine neck then replaced. MINIMAL midline tenderness. rom not tested. remainder of trauma survey nl e.d. course- c-spine films( "can we clear this guy and get him off the board for some better films"....) hold on a sec....uh, no.... fx at c2-c4 usually require a c.t.....(silence from rad techs) ct neck(per rads) multiple unstable teardrop fxs.... transfer care to neurosurgery..... morale of the story..... developmentally delayed pts with " no distress" and minimal exam findings need to be treated like folks with etoh or drugs on board or folks with a distracting injury...that is to say you can't trust the history. a "nl" pt would have said his pain was 8+ and would have been asking for pain meds....so mechanism + tenderness in a worrisome area+ poor historian= full court press workup.....glad I didn't send this guy home.....I thought about it for a sec......same is true with any medical complaint. drunks/druggies/poor historians with 1/10 rlq pain always get a ct and full appy eval if you can't trust the hx..... 1 Quote Link to comment Share on other sites More sharing options...
chatcat Posted March 8, 2007 Share Posted March 8, 2007 morale of the story.....developmentally delayed pts with " no distress" and minimal exam findings need to be treated like folks with etoh or drugs on board or folks with a distracting injury Important moral to remember for all patients who can't provide a good history. I have seen some horrible outcomes with the demented elderly as well. Thanks for sharing. Quote Link to comment Share on other sites More sharing options...
Guest jstriplets Posted March 8, 2007 Share Posted March 8, 2007 same is true with any medical complaint. drunks/druggies/poor historians with 1/10 rlq pain always get a ct and full appy eval if you can't trust the hx..... had one recently, 40ish female "drunk" per EMS. One of those just didn't feel right moments and ordered labs and CT head (which REALLY P****D the nurses off!) Sodium came back 98! Stupid intensivist orders 3%NS wide open . . . . Pt seized and now a paraplegic with a trache Quote Link to comment Share on other sites More sharing options...
Guest jstriplets Posted March 8, 2007 Share Posted March 8, 2007 With the nursing shortage have any of you noticed the number of very inexperienced nurses doing triage at your hospitals? How are you handling this? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 8, 2007 Author Moderator Share Posted March 8, 2007 With the nursing shortage have any of you noticed the number of very inexperienced nurses doing triage at your hospitals? How are you handling this? yup, it's frightening. we had a unit clerk attending an rn program who ended up at triage her 1st day as a nurse....what a mess.....we LIFEFLIGHTED pts from fast track to other facilities.....also admitted pts to icu, neuro critical care, cath lab FROM FAST TRACK.....she's not in triage anymore...but she still works in the e.r...... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 8, 2007 Author Moderator Share Posted March 8, 2007 had one recently, 40ish female "drunk" per EMS. One of those just didn't feel right moments and ordered labs and CT head (which REALLY P****D the nurses off!) Sodium came back 98! Stupid intensivist orders 3%NS wide open . . . . Pt seized and now a paraplegic with a trache hypertonic saline wide open is not a great idea....I have seen low sodiums like this brought up slowly and effectively with water restriction and GENTLE/SLOW na supplementaion.... the other "drunk" not to blow off ( as my medic partner did once) is the guy with a blood sugar of SEVEN on arrival at the e.d.......just because you spilled a beer on your shirt earlier in the day before you became altered doesn't mean someone shouldn't check your blood sugar..... Quote Link to comment Share on other sites More sharing options...
ajnelson Posted March 9, 2007 Share Posted March 9, 2007 the other "drunk" not to blow off ( as my medic partner did once) is the guy with a blood sugar of SEVEN on arrival at the e.d.......just because you spilled a beer on your shirt earlier in the day before you became altered doesn't mean someone shouldn't check your blood sugar..... On a side note...just because they are drunk (or have had a drink) doesn't mean their blood sugar can't be low. We had a frequent flier, type I DM, bouncer at a bar and frat boy. Needless to say he had lots of trouble maintaining his sugars w/the ETOH use. Those of us that worked the area knew him, but the new guys always jumped the gun thinking he was "drunk". He actually amazed me...he would still be able to talk and carry a pretty normal conversation with a blood sugar of 20-30 :eek:, and knew he was going downhill quickly! Quote Link to comment Share on other sites More sharing options...
Guest ER_PA Posted July 17, 2007 Share Posted July 17, 2007 How about the 35 y/o diabetic IVDA known drug seeker that comes in for the 3rd time this week for back pain but this time has a Low Grade Fever of 100.9 Nurse shrugs it off b/c its 95 degrees outside and he's a "regular" Quote Link to comment Share on other sites More sharing options...
andersenpa Posted July 17, 2007 Share Posted July 17, 2007 How about the 35 y/o diabetic IVDA known drug seeker that comes in for the 3rd time this week for back pain but this time has a Low Grade Fever of 100.9Nurse shrugs it off b/c its 95 degrees outside and he's a "regular" Yup, good old "regular" epidural abscess, "regular" osteo.....:eek: Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 2, 2007 Author Moderator Share Posted November 2, 2007 had a guy tonight I was just positive had a dissecting AAA....65 yrs old, very hypertensive, pale as a ghost, diaphoretic, vomiting profusely due to abd/flank pain, no relief with iv dilaudid......turns out that a 15 mm(!!!!!) kidney stone can make you look like that.....it was in my ddx...after aaa and atypical mi(guy had inferior ekg changes old vs new with no old ekg to compare)....fortunately his stone was large enough that it showed up on the ct with iv contrast....a neg ct report would have gotten this guy a vascular surgery consult +/- trip to the cath lab..... Quote Link to comment Share on other sites More sharing options...
medic25 Posted November 2, 2007 Share Posted November 2, 2007 Had a scary one in urgent care last week. Woman in her 40's, triage note says "medication request", claims she strained her back doing housework. HR of 105, vitals otherwise normal. She complains of pleuritic upper thoracic pain, and some shortness of breath. Taking a little bit of a history, turns out shes already had two DVT's, and stopped her Coumadin a few months ago without telling her doctor. CXR shows a pleural effusion on the painful side, and D-dimer is almost 4 (normal <1.4). I ended up heparinizing her before the CT scan, which showed multiple, bilateral segmental and subsegmental PE's! Spoke with her PMD, she turned out to be Factor V Leiden deficient, and apparently didn't quite grasp her condition. Very glad I didn't follow her request and just give her a "pain pill" to help her sleep.... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 2, 2007 Author Moderator Share Posted November 2, 2007 ah, triage...last week had a guy with new onset dm with dka. kusmaul resps around 60/min, blood sugar 696, ph 7.0, real case...triage note..."cold sx for 2 days with cough......." Quote Link to comment Share on other sites More sharing options...
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