pwauburn Posted May 17, 2009 Share Posted May 17, 2009 A good sphincter tightener. I work in trauma, and during our f/u trauma clinic, a recent d/c from a serious motorcycle accident came for his 2 week f/u. He was a cool guy, and told me he was doing much better. Just had the normal trauma complaints, then at the end of his history his son reminded the patient "don't forget about the pain you had last night daddy." Patient went on to explain this "tearing sensation" in his mid chest that he best described as feeling like velcro tearing in his chest and it hurt like hell (seriously, I did not use any leading questions). At the time during clinic, he stated that the pain was much better 2-4/10, but it was still present. I tried to act as calm as I could because I didn't want to get him worked up and drive his B/P up. I then went and started the order form for a stat CT angio of chest, and told my doc of the situation. The doc went in and very calmly stated that we wanted to get a special picture of his chest just to see if he had a pneumonia, recurrent ptx, or possibly some other stuff. I'm glad doc was there, because I was worried that if I opened my mouth again I was going to say something like "holy ****! get in the wheelchair and relax!!" End result was that the patient just had a pneumonia, that has now been dealt with. All of his vessels were fine, and there was no recurrence of the pneumothorax. However, that was one of the worst feelings that I have ever had when he started to explain his recent symptoms coupled with his recent trauma, and the fact that his young son was sitting there next to him. Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 17, 2009 Share Posted May 17, 2009 Thank goodness it wasn't a dissection! but good for you for making sure. Patient safety first.... A good sphincter tightener. I work in trauma, and during our f/u trauma clinic, a recent d/c from a serious motorcycle accident came for his 2 week f/u. He was a cool guy, and told me he was doing much better. Just had the normal trauma complaints, then at the end of his history his son reminded the patient "don't forget about the pain you had last night daddy." Patient went on to explain this "tearing sensation" in his mid chest that he best described as feeling like velcro tearing in his chest and it hurt like hell (seriously, I did not use any leading questions). At the time during clinic, he stated that the pain was much better 2-4/10, but it was still present. I tried to act as calm as I could because I didn't want to get him worked up and drive his B/P up. I then went and started the order form for a stat CT angio of chest, and told my doc of the situation. The doc went in and very calmly stated that we wanted to get a special picture of his chest just to see if he had a pneumonia, recurrent ptx, or possibly some other stuff. I'm glad doc was there, because I was worried that if I opened my mouth again I was going to say something like "holy ****! get in the wheelchair and relax!!" End result was that the patient just had a pneumonia, that has now been dealt with. All of his vessels were fine, and there was no recurrence of the pneumothorax. However, that was one of the worst feelings that I have ever had when he started to explain his recent symptoms coupled with his recent trauma, and the fact that his young son was sitting there next to him. Quote Link to comment Share on other sites More sharing options...
mytopeka Posted May 19, 2009 Share Posted May 19, 2009 Today from fast track: Healthy looking 42 year old guy, no acute medical hx, tells me he has a white rash on his penis for 2 days. He was convinced the rash started after he peed in a paint can. And it hurts when he pees. Urine negative for infection, but glucose >1000. Labs ordered. Admitted to the ICU 2 hours later with DKA. I only saw the guy in the hallway. I was waiting to get him in a room before I took a look at the rash but my attending had to take over so he could admit. I never got to see the rash. Hope it wasn't paint. Quote Link to comment Share on other sites More sharing options...
rcdavis Posted May 19, 2009 Share Posted May 19, 2009 the rash was candida of the glans. almost pathopneumonic: candida on the glans in an adult = diabetes until proven otherwise. v/r davis Quote Link to comment Share on other sites More sharing options...
andersenpa Posted May 19, 2009 Share Posted May 19, 2009 the rash was candida of the glans. almost pathopneumonic: candida on the glans in an adult = diabetes until proven otherwise. I guess he was confusing "candida on the glans" with "glans in the can"....... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 19, 2009 Author Moderator Share Posted May 19, 2009 I guess he was confusing "candida on the glans" with "glans in the can"....... some people are glans half full types and others are glans half empty.... Quote Link to comment Share on other sites More sharing options...
Guest rdennisjr Posted May 19, 2009 Share Posted May 19, 2009 You couldn't even get a quick 'glans' at it? It might have been the tip of the spear... D Quote Link to comment Share on other sites More sharing options...
rcdavis Posted May 20, 2009 Share Posted May 20, 2009 ohhhhhhhh myyyyyyy. post just one little comment, and look what happens... :) 1 Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 20, 2009 Share Posted May 20, 2009 You boys are something else. Always good for a laugh :p Quote Link to comment Share on other sites More sharing options...
dkspain Posted July 16, 2009 Share Posted July 16, 2009 Three interesting fast-track folks in the past week. 1. ectopic -- MILD rlq tenderness. Not an earth-shattering diagnosis to remember ectopic until proven otherwise -- but good illustration of bad triage -- cc was "vag bleeding" and NEVER trust the triage RN note of "pt took pregnancy test at home 2 weeks ago and it was negative...." ummmm 2. Compartment syndrome -- my seasoned attending said that was the first real case of it he's seen. Of course I've thought EVERY person with "numbness" in the hands (in my pt population "numb" = "throbbing pain" I've decided) in my last 8 mo as a new grad is compartment syndrome, but this time was fo' real! Had all of the 5 P's, except for pulselessness, which is of course a late finding. Ortho booked for OR before even checking compartment pressure just based on clinical finding. 3. Person with neck disc fusion 6 days previously -- c/o difficulty swallowing ('feeling of choking'), sob with lying down, wound leaking from the incision site. Apparently difficulty swallowing and hoarseness are common after this procedure per his ortho on-call, but increasing symptoms concerning. Sure enough, CT neck revealed a hematoma encroaching on his airway. Just another fast track to ICU admission! For every fast-track disaster I catch, the fear looms greatly of those that might have walked out the door that you didn't realize! Residency starts next month -- can't wait! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 16, 2009 Author Moderator Share Posted July 16, 2009 2. Compartment syndrome -- my seasoned attending said that was the first real case of it he's seen. Of course I've thought EVERY person with "numbness" in the hands (in my pt population "numb" = "throbbing pain" I've decided) in my last 8 mo as a new grad is compartment syndrome, but this time was fo' real! Had all of the 5 P's, except for pulselessness, which is of course a late finding. Ortho booked for OR before even checking compartment pressure just based on clinical finding. I have seen maybe 5 legitimate cases of compartment syndrome. the key is pain out of proportion to exam. each one of them howled with light touch of the involved area. the inflamation/tightness is usually impressive on its own as well. numbness as a single sx is too vague and usually does not represent compartment syndrome. best case of compartment syndrome I have seen was a 55 yr old guy with afib on coumadin in a minor mva. thigh vs dash. no fx. his compartment pressure was higher than the top of the striker gauge. Quote Link to comment Share on other sites More sharing options...
medic25 Posted July 16, 2009 Share Posted July 16, 2009 I read an interesting journal article earlier this week about the use of a thermal imaging camera to diagnose compartment syndrome. It basically compared the surface temperature of a patients leg distally and proximally; patients with a compartment syndrome were found to have a cooler surface area over the affected region than the rest of the body. If I can find the article again I'll post it. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 25, 2009 Author Moderator Share Posted July 25, 2009 50 yr old obese, smoking, htn male pt (with new onset dm dx this visit and strong fh of cad and dm) presents with chest "burning" x 8 hrs after 35 mile bike ride-doesn't normally exercise, decided now was the time to jump right in and get in shape.. appears pale. initial ekg: sinus rhythm at 86/min, no ectopy, ischemic changes in lateral leads.... standard cardiac workup done, given asa, some improvement with 02/nitro/morphine....troponin #1.....13.5.....to cath lab.....almost complete lad lesion, stented...reflex troponin #2= 50.0 Quote Link to comment Share on other sites More sharing options...
doghead Posted August 30, 2009 Share Posted August 30, 2009 try to guess the ADMITTING dx for each of these recent fast track complaints. let's see who can get them all first. some are easy, some aren't....gotta stay on your toes even in fast track folks.... diabetic 50 yo m with "shoulder pain" 85 year old htn male with atraumatic "neck pain" 30 yr old fe on o.c.'s with "blurry vision" 75 year old male with worsening "leg pain" x weeks 35 yr old fe with btl with "bad gas pains and dizzyness" 17 year old fem with "yeast infection and fever" 18 yr old male iddm pt with" new onset asthma" 50 yr old morbidly obese poorly controlled htn m with "heartburn" 45 yr old fe "bleeding gums" 22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v" 1-STEMI 2-vertebral A dissection 3-micro emboli 4-slow leak AAA 5-ectopic, likely ruptured 6-PID with sepsis 7-DKA with compensatory resp alkalosis 8-ACS 9-thrombocytopenia ,itp 10-NSAID induced gastritis r/o peptic ulcer vs preg Quote Link to comment Share on other sites More sharing options...
doghead Posted August 30, 2009 Share Posted August 30, 2009 I totally agree with Dave. I have 5 years of working experience in er and almost 7 years in fast track and let me tell you that some of the scariest and most risky cases that I have seen were in the fast track. You have to be a really confident PA in my opinion to work independently and manage fast track patients. Some days I would admit more from the fast track then I would from the ed! A newbie just can't handle it. And on top of that you have less nursing staff in the fast track and more time constraints. Quote Link to comment Share on other sites More sharing options...
doghead Posted August 30, 2009 Share Posted August 30, 2009 It seems that we all work in the same place! I've seen more bad nurses let go for calling out sick than being a threat to patients!!!!!!!!:eek: And you know the scary thing is that even if you do everything right and the patient ends up having a bad outcome once admitted, you may still be sued. Make sure that your malpractice insurance doesnt have specific exclusions of what they will cover when you are in the fast track vs ed. I know that some of the docs I worked with in the fast track were not insured to see MI's while they worked there. The hospital assumes that these types of sick patients, MI's, septic pts, unstable abdominal pains, etc, are being seen in the main ED and if you have a claim brought against you then the hospital may liable you if you are indeed practicing outside your scope of practice in the fast track. And the plaintiffs lawyer will just see that the patients care was either delayed or that standard of care was not met because you put your patient in harms way by keeping him or her in the fast track instead of transfering them to the ed. You will own that pts problems. Make sure that you are insured to see these types of patients in the fast tracks. A non monitored bed should not be housing a chest pain pt., etc. Protect yourself because the nurses wont. They just want the patients to go away and they want to alleviate the stress on the ed side. They dont care about the fast track. At least that is how it seems sometimes. I have had to wheel my pts over to the main ed on my own at times. No one likes confrontation, but you need to do it to protect yourself and the patient. I think as ED's get more crowded this will become an even bigger problem and we will start to see legal ramifications from this trend if we are not diligent in being the pt's advocate. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 4, 2010 Author Moderator Share Posted August 4, 2010 ok, time to update this thread...here's one from this wk..... 24 yr old female triaged to fast track for " R chest wall strain".....hmm, ok chest pain basically....so what's the worst case scenario? MI, PE, thoracic dissection, esophageal rupture, pneumothorax, etc....the role of em is to exclude all of these of course....so here goes.... c/c "chest strain" x 2 days. no known cause. rates pain 6/10 with movement and inspiration. awoke with pain. no travel, no ca hx, no recent surgery/trauma ros no fever, no hemoptysis, no leg swelling, no palpitations, no rash( it ain't shingles) pmh: none surg: none meds: depo provera all: none FH: no early MI, no dvt/pe sh 1/2 ppd smoker, no st drugs, employed, occ. etoh O: wt fe/caox4/nad vs: t 37.2, p 74, bp 110/68, r 22, sao2 99% ra exam completely benign aside from some apparently mild inspiratory r chest pain labs: cbc nl, cmp nl, ua, nl, ucg + ("WTF, I'm on depo and my period isn't even late") serum hcg 850 ekg nsr 75, no ectopy cxr (shielded) nl..... ok, well perc criteria says resp rate less than 20 and she is 22 so can't rule out PE ...also pregnant on depo and smokes so got to r/o PE....ok... .....d-dimer.....965 ( + = >500)...well, pregnancy can cause an elevated dimer....got to scan her...long discussion with pt about risks of radiation to herself and fetus, signed consent....now we are at about 90 min for a "fast track pt"....cta shows MULTIPLE R SIDED PE'S WITH LARGE INFARCT.....crap.....lovenox, admission, etc......gotta love it...multiple pe's in F.T....and would have been an easy miss..... another one from one of my( truly excellent) attendings...7 yr old kid who won't bend his neck in any direction x 2 days... in brief: no trauma, no fever, no drooling, not ill appearing, no sore throat...playful in exam room, doesn't look sick enough to tap. benign throat exam(neg strep from triage)....doc orders ct of c-spine looking for locked facets....dx LARGE RETROPHARYNGEAL ABSCESS.......crap...we all agreed this was a very close near miss...the doc in question said he was thinking about giving some motrin and t3 elixir and sending home and calling it torticollis and didn't even have abscess in his ddx........ Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted August 4, 2010 Share Posted August 4, 2010 OK, time to update this thread...here's one from this wk.....24 yr old female triaged to fast track for " R chest wall strain".....hmm, OK chest pain basically....so what's the worst case scenario? MI, PE, thoracic dissection, esophageal rupture, thorax, etc....the role of em is to exclude all of these of course....so here goes.... c/c "chest strain" x 2 days. no known cause. rates pain 6/10 with movement and inspiration. awoke with pain. no travel, no ca hx, no recent surgery/trauma ros no fever, no homeostasis, no leg swelling, no palpitations, no rash( it ain't shingles) pmh: none surg: none meds: depo provera all: none FH: no early MI, no dvt/PE sh 1/2 ppd smoker, no st drugs, employed, occ. etoh O: wt fe/caox4/nad vs: t 37.2, p 74, bp 110/68, r 22, sao2 99% ra exam completely benign aside from some apparently mild inspiratory r chest pain labs: CBC nl, cmp nl, ua, nl, ucg + ("WTF, I'm on depo and my period isn't even late") serum hcg 850 EKG nsr 75, no ectopy cxr (shielded) nl..... OK, well perc criteria says resp rate less than 20 and she is 22 so can't rule out PE ...also pregnant on depo and smokes so got to r/o PE....ok... .....d-dimer.....965 ( + = >500)...well, pregnancy can cause an elevated dimer....got to scan her...long discussion with pt about risks of radiation to herself and fetus, signed consent....now we are at about 90 min for a "fast track pt"....cta shows MULTIPLE R SIDED PE'S WITH LARGE INFARCT.....crap.....lovenox, admission, etc......gotta love it...multiple pe's in F.T....and would have been an easy miss..... another one from one of my( truly excellent) attendings...7 yr old kid who won't bend his neck in any direction x 2 days... in brief: no trauma, no fever, no drooling, not ill appearing, no sore throat...playful in exam room, doesn't look sick enough to tap. benign throat exam(neg strep from triage)....doc orders ct of c-spine looking for locked facets....dx LARGE RETRO PHARYNGEAL ABSCESS.......crap...we all agreed this was a very close near miss...the doc in question said he was thinking about giving some motrin and t3 elixir and sending home and calling it torticollis and didn't even have abscess in his ddx........ Studly work!!!!! No hypoxia, tachynpnea or tachycardia she could have gotten by almost anyone except EMEDPA. Not a pure bred horse , but clearly part zebras! Something to be said about clinical gestalt! Quote Link to comment Share on other sites More sharing options...
Devildog Posted August 4, 2010 Share Posted August 4, 2010 "multiple pe's in F.T." I dont mind showing my ignorance... does this mean "in the fetus?" Quote Link to comment Share on other sites More sharing options...
delco714 Posted August 4, 2010 Share Posted August 4, 2010 Fast track.. ft usually doesn't see such cases, but it does happen alla emed's findings ;) Quote Link to comment Share on other sites More sharing options...
Guest guthriesm Posted August 4, 2010 Share Posted August 4, 2010 EMEDPA - make your patient 25 and not pregnant and you just described a family member of mine. CC: chest pain. She had been seen by FNP and had pneumonia ruled out with X-ray (history of cold symptoms and asthma x 1 week). FNP treated with nebulizer and sent home. 3 days later I take her to ER for increasing pain. Triaged @ 5 (normal O2, slightly tachycardic), waited 4 hours to be seen D-dimer elevated. CT revealed multiple PE's including one large. Immediate admission to ICU. Followed up for almost a week due to severe tachycardia (>200 on bed rest) and home on coumadin for 6mo. Thank goodness for alert provider- he said he was doing the ddimer as a CYA. Quote Link to comment Share on other sites More sharing options...
lightbearer06 Posted August 5, 2010 Share Posted August 5, 2010 Crazy one that one of my SP's had in urgent care several weeks ago. 11 or 12 yo F with complaint of abdominal pain x 1 week. Mildly tachycardic, otherwise normal vitals. Physician elicited history of somewhat recurrent which had been diagnosed as gastroenteritis about a year ago. No N/V/D currently. Now, patient is in severe pain. "Rigid" abdomen, diffusely tender. Physician orders labs. All normal except positive HCG. He immediately goes back in and starts asking about sexual history. Normal periods, swears no sexual intercourse. Physician transfers to ED where she is found to have a malignant teratoma. She is undergoing chemo now and possibly surgery at some point. Quote Link to comment Share on other sites More sharing options...
Febrifuge Posted February 20, 2011 Share Posted February 20, 2011 I should have either been reading this thread when I started soloing in the urgent care a few months ago, or stayed the hell out of it. I'm getting nervous now! Quote Link to comment Share on other sites More sharing options...
Guest guthriesm Posted February 22, 2011 Share Posted February 22, 2011 I think the take home message- think horses, not zebras but don't forget there *are* zebras. Often things can be ruled in/out by a solid patient history (like the patient with NO intercourse or a woman on BCP, etc) followed by some pretty basic tests. Quote Link to comment Share on other sites More sharing options...
nebero Posted April 27, 2011 Share Posted April 27, 2011 Another fast track case ended up admitted 20 Y/O Male with no PMH came in complaining of nausea and vomiting. He mentioned that earlier he had a headache and took some "baby asprin" and went to bed. Woke up after a couple of hrs and started to have nausea and vomiting. Girlfriend dragged him in to the ER where he was triaged as a 4. I saw him and asked about his symptoms. HA has resolved, N/V is improving, states that the only thing that bothers him is "ringing in my ear" but it is also getting better. pt is eager to go home as he has to wake up early to go to work. Vitals and physical exam are unremarkable. The guy is giggling and having a good time in the exam room with what looks like a new girlfriend. I ordered basic labs including Asprin level. Everything came back negative except Asprin level of 67.5mg/dl. If i remember correctly normal is below 30-35. I contacted Poison control and they were shocked that his other labs and vitals are normal. They called the level a "sucide amount". I went back to the room and told pt to slow his horses down as we have something serious here. At that point he was ready to go because "I feel normal now". I asked again how many asprins he took and he said 7-8. I asked if they were really baby asprins. His answer now is "they are kind of small". Girlfriend went home and brought the bottle and they happened to be 325mg pills. I still thought that he took more than 7-8 pills. I repeated asprine level again and still came back extremely elevated at 58mg/dl. Now my attending and I run around to order some more tests and find him some one for admission. The guy remained stable. Of course all these happened towards the end of my shift which supposed to be 3AM and when I get home it was time for breakfast before i go to bed. Lesson I learned; Baby asprin for health care professionals is 81mg and for pts it is the "kind of small pills". I wonder if there is baby Metformin and baby HCTZ in pt's world. Once again, NEVER TRUST THE MEDICATION HISTORY COMPLETELY UNLESS YOU SEE THE ACTUAL BOTTLES Quote Link to comment Share on other sites More sharing options...
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