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SERENITY NOW

"The test is negative... discharged!" Occult EM - test negative misses

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Another theme I've noticed during my first years out was anchoring on sick contacts as a definitely benign sign...  of course it most often is, but are there things you should consider and ask about in HnP before anchoring on a benign infectious process?

 

case 16.  21 year old male living in a fraternity comes in for malaise, sore throat, feeling feverish, headache, body aches.  His roommate is sick with similar syndrome --> strep test is negative --> do you discharge him?  What else is on your ddx?  

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20 hours ago, SERENITY NOW said:

Another theme I've noticed during my first years out was anchoring on sick contacts as a definitely benign sign...  of course it most often is, but are there things you should consider and ask about in HnP before anchoring on a benign infectious process?

 

case 16.  21 year old male living in a fraternity comes in for malaise, sore throat, feeling feverish, headache, body aches.  His roommate is sick with similar syndrome --> strep test is negative --> do you discharge him?  What else is on your ddx?  

More than 1 person with similar symptoms usually prompts me to check VBG for carboxyhemoglobin level. Many very benign presentations with high risk for bad outcome if missed.

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6 hours ago, LA_EM_PA said:

More than 1 person with similar symptoms usually prompts me to check VBG for carboxyhemoglobin level. Many very benign presentations with high risk for bad outcome if missed.

Bingo!  CO poisoning is one of two emergency ddx that comes to mind if someone else at home has it as well.  Anybody care to guess the other one?  Our standard blood work and viral testing would miss this other dx, so you have to know to look for it and its largely a clinical suspicion thing. I'll give a clue... the nurse comes to you and gives you an update while waiting for tests to come back, "hey FYI that guy in room 8 seems like he is getting one of those "viral exanthems" - small spots of pink / red popping up throughout body.  You press on it and it doesn't blanch.  Thoughts?

 

 

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Does the patient turn their head to look at you when you walk into the room or does their whole torso turn?  Colleges are one of many settings for outbreaks of menningitis.

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Thats the second one!  One of the risk factors for meningitis is close quarters with others who might have some part of the spectrum of illness.  Now, whenever I hear about positive sick contacts, I make sure to consider, and document, why I don't think its meningococcus or CO poisoning before labelling them as URI.  

 

I've been thinking about this a lot lately... so much of our job is pattern recognition, and exercises like in this thread is all about recognizing those triggers that should make you stop and take a second to think, "I remember this could represent something easily missed".  

 

If anybody else has cases / examples to share, please post them!

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Another trap came to my mind today that is along similar line of thinking as "oh there are sick contacts so its probably benign" is the trap of "spontaneously improving symptoms, so it must be benign".  This happens all the time; the triage team will come up to me and ask if I can go discharge this patient from the waiting room "because their symptoms have resolved while they were waiting and they're asking if they can go!"  It would be very easy to turn the brain off and do it, but beware!

Spontaneous improvement still happens in bad disease:

-SAH

-TIA

-CO poisoning

-Intussusception 

-intermittent torsion

-I'm sure there are many more.....

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I've responded to lots of "CO checks" over ~35 years in the fire service.  CO poisoning isn't all that common - frankly pretty rare.  Before ordering bloodwork, ask about sources, i.e. actual combustion: gas/oil/propane/wood furnaces, stoves, hot water heaters, or tools/vehicles with internal combustion engines in enclosed spaces or possibly improperly vented.  I've had more than a few folks complain of s/s in fully electric residences and readings of zero on meters.  The local FD can typically check the house or workplace pretty quickly to determine if CO is present at concerning levels.

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Totally agree and thank you for the post.  I didn't want to suggest that people simply order tests for these possibilities, but to avoid anchoring and at least keep it on the ddx and ask those questions like you mentioned.  

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