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so have had 2 pts in the last 48 hrs with metastatic cancer as the cause of their chronic back pain. both frequent ER fliers. both tagged all over the chart by myself and others (including their own pcps) as drug seeking....both seen by other providers within the last month. humbling experience. Both seen so many times that it was hard to take them seriously, but they both stated sudden worsening so I MRI'd one and CT'd another. both with disseminated metastatic dz.....well, crap.....

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11 minutes ago, Jackofallmasterofnone said:

Good reminder that even the boy who cried wolf has real issues even if once in a blue moon.

yup, one of our other frequent fliers who would call 911 for Ativan refills for pseudoseizures recently died because no one took them seriously when they came in after a "seizure" (like the 50+ other visits for same). neurology had even been consulted on them and written "do not give this pt benzos" in their chart. they were left in an unmonitored hall bed on a busy day and found dead shortly thereafter. The ER provider(not me) was able to resuscitate them and they were sent to the icu, where they died a few days later. Inoperable head bleed.

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I think you hit on the dilema: what S/S, physical exam findings, etc raise the red flag that this time we need to look deeper?  One obvious one is a patient report (creditable) that their s/s are different from their chronic.  Another notion would be what base line "screening" workup is appropriate.  Even all of the scoring tools have some level of false negatives associated with them.

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  • 3 weeks later...
On 2/26/2019 at 1:41 PM, Jackofallmasterofnone said:

Good reminder that even the boy who cried wolf has real issues even if once in a blue moon.

The way we were taught in school was that even crazy people/malingerers get sick...

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ok, confession time...this time it got me...frequent flyer with abd pain, negative recent huge workup with neg labs/ct, etc. Nurses moaning when they see them arrive. so and so is here again for constipation. complaint" I need you to give me something to help me poop, I have not pooped all day". minimal exam on my part. no complaint of abd pain, fever, vomiting, etc. discharged within 15 of arrival with rx for miralax. call from local hospital 6 hrs later. pt presented there with abd pain, fever, and n/v. cbc with leukocytosis. ct shows perfed appy. surgeon was pissed. fair enough. I went and saw the pt and apologized. They realized it was atypical and did not seem upset. I blew it. it happens. anchoring bias, playing the odds, and minimizing common sense....I hope to learn from this. 

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Resurrecting this post as I just started in the ER 1 month ago after 6.5 years in UC.  And we have a LOT of frequent flier abdominal pain patients.  Some have gotten so many CT's that radiology refuses to scan them anymore.  Their exams are always difficult because they are overly dramatic and histrionic.  Obviously, we can't scan them every single time they come to the ER.  Tips on risk stratifying these folks to avoid making them glow?  I feel like CBC is unreliable (I had a abscessed appy the other day, wbc 7.0).  Are you guys checking lactate or procalcitonin on these folks to help?   And what about your chronic migrainer/pseudoseizure patients?  Do the best neuro exam you've done since school?   And the nurses are so burnt out on these folks it's difficult to do anything.  

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13 minutes ago, DogLovingPA said:

 I feel like CBC is unreliable (I had a abscessed appy the other day, wbc 7.0).  Are you guys checking lactate or procalcitonin on these folks to help? 

Have no idea how much play the neutrophil:leukocyte ratio (NLR) is getting in the ED world but I just saw a post breaking down the predictive value of the NLR vs Leukocytosis in appy's a couple hours ago!  Link below...

https://emcrit.org/pulmcrit/nlr/

Edited by MediMike
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Bedside sono if available, and if not get a sono. You’ll at least cut down on the glow factor for the possible appendicitis cases/pelvic abscesses. Same for kidneys. Looking back, I profoundly underutilized this option, because you couldn’t usually get one in a timely manner.

Old man syndrome here but this is where development of clinical skills comes into play. Appy? Can they drop hard onto heels, or if a kid, can they hop on a leg? Even if you miss it initially they’ll be back. It’s always fun to send home an appy telling them that they have a hot appy, and to come back later when it worsens because the surgeon won’t cut on them at that point.

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3 hours ago, GetMeOuttaThisMess said:

Bedside sono if available, and if not get a sono. You’ll at least cut down on the glow factor for the possible appendicitis cases/pelvic abscesses. Same for kidneys. Looking back, I profoundly underutilized this option, because you couldn’t usually get one in a timely manner.

Old man syndrome here but this is where development of clinical skills comes into play. Appy? Can they drop hard onto heels, or if a kid, can they hop on a leg? Even if you miss it initially they’ll be back. It’s always fun to send home an appy telling them that they have a hot appy, and to come back later when it worsens because the surgeon won’t cut on them at that point.

We can get sono at any time but our radiologists would apparently prefer that we not for appys as they don't feel comfortable reading them (at least for peds).  I have zero sono experience beyond abscess vs cellulitis (looking to change that).  A handful of my attendings will pull it out for a look at a gall bladder or a FAST exam, but beyond that we don't use the bedside sono much.   I can get reliable pelvic US at all times which is nice.  For kids, I certainly have them jump up and down, etc.  The dramatic frequent flying adults however get a lot more complicated.  Thanks for the tips.

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44 minutes ago, EMEDPA said:

I had a surgeon tell me awhile ago " it is impossible to have appendicitis with a normal CRP" so I am getting them a lot more often now, whether or not he is right. 

Good to know.  Certainly easy enough to add to the workup.  I imagine this would hold true for other infectious dx of the abdomen as well?  Diverticulitis, etc?

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2 hours ago, EMEDPA said:

I had a surgeon tell me awhile ago " it is impossible to have appendicitis with a normal CRP" so I am getting them a lot more often now, whether or not he is right. 

I think that I may have mentioned this here in the past, in my first ED job we had a radiologist who had picked up on the fact that appendicitis cases on an upright KUB did not have stool in the ileocecal/RLQ since the inflammation either moved it past out of the way, or else wouldn't allow it into the area due to inflammation.  Your mileage may vary.

Last rule of thumb for appy cases was to sono and if appendix was visualized and appeared normal then look elsewhere.  If not visualized, or abnormal in appearance, then CT.

Edited by GetMeOuttaThisMess
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On 11/12/2019 at 8:13 AM, DogLovingPA said:

Obviously, we can't scan them every single time they come to the ER.

Yes we can

On 11/12/2019 at 8:13 AM, DogLovingPA said:

And what about your chronic migrainer/pseudoseizure patients?

Migrainer:  no focal deficit = doubt a space occupying lesion.  No sudden onset = doubt SAH.  Feels better with toradol = go home.

Pseudoseizure:  I call it seizure-like activity and once back to baseline they go home, frequently without any testing. 

On 11/12/2019 at 8:13 AM, DogLovingPA said:

And the nurses are so burnt out on these folks it's difficult to do anything

It's our job to hold the line.

Edited by Boatswain2PA
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Quick and dirty neuro exam:

  • Watch them walk into the room
  • See if they are texting.  If they are, that covers most of the cranial nerves, finger to nose test, etc.
  • Talk to them while moving about the room, watch for focal deficits and EOM's.

If all are normal, pretty low likelihood of any focal deficit.

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6 minutes ago, ohiovolffemtp said:

Quick and dirty neuro exam:

  • Watch them walk into the room
  • See if they are texting.  If they are, that covers most of the cranial nerves, finger to nose test, etc.
  • Talk to them while moving about the room, watch for focal deficits and EOM's.

If all are normal, pretty low likelihood of any focal deficit.

sounds like a Greg Henry neuro exam: see them walk, hear them talk, look in their eyes. 

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I think this is one of the most difficult things in medicine. I had a patient who was #1 in my panel for both drug seeking and somatization disorder. She also had habit of lying about many things. She was (hate to use the past tense) only 35. She seemed to disappear for a while and came back to see me. She told me she had metastatic cancer ( I won't say which type because I don't want her family connecting the dots to her case here in the webosphere) and had weeks to live. I was doubtful and had her records sent to me (after her approval). I read through them, from her first complaint of new pain, to her final diagnosis, to chemo failures and turning her over to hospice. She was telling the truth this time. But the pattern I saw was that she was not taken seriously at first because she was always in some clinic, ED, urgent care, etc. looking for benzos or narcotics and with bizarre complaints and fears of disease. I was not in this loop as I see her just for her migraines. I suspect those in the loop, who dismissed her early complaints, will be sued. But sometimes there is a woof, but, on the other hand, you simply cannot run extensive tests on everyone with every new complaint, especially when they are histrionic.

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On 11/20/2019 at 1:31 PM, jmj11 said:

I think this is one of the most difficult things in medicine. I had a patient who was #1 in my panel for both drug seeking and somatization disorder. She also had habit of lying about many things. She was (hate to use the past tense) only 35. She seemed to disappear for a while and came back to see me. She told me she had metastatic cancer ( I won't say which type because I don't want her family connecting the dots to her case here in the webosphere) and had weeks to live. I was doubtful and had her records sent to me (after her approval). I read through them, from her first complaint of new pain, to her final diagnosis, to chemo failures and turning her over to hospice. She was telling the truth this time. But the pattern I saw was that she was not taken seriously at first because she was always in some clinic, ED, urgent care, etc. looking for benzos or narcotics and with bizarre complaints and fears of disease. I was not in this loop as I see her just for her migraines. I suspect those in the loop, who dismissed her early complaints, will be sued. But sometimes there is a woof, but, on the other hand, you simply cannot run extensive tests on everyone with every new complaint, especially when they are histrionic.

This.  The line is difficult.  And if you do run every test on these folks I feel like to some degree you feed their anxiety as well.  Definitely a very difficult group of patients.  Along with the pan positive ROS folks.  It doesn't help that most of these folks tend to try our patience so we are already more likely to pay less attention to their complaints.  It takes a lot to check our own biases.

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