Moderator EMEDPA Posted September 22, 2012 Moderator Share Posted September 22, 2012 female in her late 30's presents with back pain and abddominal pain x 1 hr. very strange affect. hysterical/dramatic. diaphoretic. pulse found to be >250 with ok bp. placed on monitor and ekg obtained. afib/flutter with rapid avr. transient slowing with 20 mg cardizem IV. sedated and cardioverted into sinus rhythm but 10 min later back in afib around 130/min. drug screen surprisingly neg(assumed meth or cocaine). Troponin nl. tox screen nl. tsh < .008. free t4=5 (high nl around 2.4). thyroid storm. very cool. admitted to the icu to be further managed by the intensivist. Link to comment Share on other sites More sharing options...
rcdavis Posted September 22, 2012 Share Posted September 22, 2012 Great setting for IV beta blockers Link to comment Share on other sites More sharing options...
d2305 Posted September 22, 2012 Share Posted September 22, 2012 You got the tsh back quick. Link to comment Share on other sites More sharing options...
Hemegroup Posted September 22, 2012 Share Posted September 22, 2012 nice! good one to never forget. wasn't that a corey hart song? or wait, never surrender ... i dunno. nice! Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 22, 2012 Author Moderator Share Posted September 22, 2012 Great setting for IV beta blockers YUP, ended up using labetalol. initially we all thought she was lying and using cocaine.... Link to comment Share on other sites More sharing options...
Contrarian Posted September 23, 2012 Share Posted September 23, 2012 While this case was not by any means common... This is the type of $hit I see a few times a month in Inpatient Psychiatry. Typically, the ED calls our free standing lockdown psych unit for a bed for Josephine Snuffy because she is acutely psychotic and bizzare. They seem REALLY interested in getting this patieht/bother/pain off their unit. Since this is a free standing secure psych facility... and we have no lab or imaging or real ancillary emergency support aside from dialing 911 like the rest of the population... The Charge Nurses have been extensively trained to triage and screen potiential problems BEFORE they are admitted to the facility. Our mindset is... the patient is already sitting in a building full of million dollar screening, diagnostic tools and specialists that know how to use them. USE them BEFORE the patient gets to us instead of having to send a patient back out due to a oversite. We also try to avoid prescribing mind altering drug for a problem easily corrected by managing obvious organic causes. Soooo... The Charge Nurse screens the required faxed paper work, sees that the ED provider has noted several (5-6) times in their dictation that the patient has a PMH of Thyroid disease and liver disease... then the Charge Nurse calls the ED back to inqure about the missing Thyroid labs and then requests a TSH and a Ammonia Level with results called/faxed back to us PRIOR to us accepting and then transporting patient. [For the newbies... extreme Hypo/Hyperthyroidism and Hepatic encephalopathy and Urine infections can cause overt psychosis. This is easily fixable and I'd hate to put you, your mom, or grandmother on heavy duty AntiPsychotics when what was needed was Thyroid meds, Lactulose or antibiotics] Some physician then gets on the phone and starts going on and on about how in his/her opinion based upon his/her obviously superior training... and tha notion that the patient has a history of mental illness, is under 60 and therefore doesn't need a TSH or NH3 or Tox screen, or UA C&S and that they hadn't considered encephalopathy, but that their medical judgement will not be directed by a Nurse, PA, NP... blah... lah.... ah... h. The nurse then calls me and gives me the number to contact this ED/physician. I usually call, listen to the diatribe and pomposity... then calmly state... "Umm, DR... I'm NOT trying to dictate your practice of medicine... so no... I'm NOT trying to tell YOU what tests to order. So NO... YOU don't have to order the labs we asked for... but that patient will NOT be admitted here without them. Have a nice evening DOCTOR... CLICK (Dialtone). Link to comment Share on other sites More sharing options...
Moderator ventana Posted September 25, 2012 Moderator Share Posted September 25, 2012 While this case was not by any means common...This is the type of $hit I see a few times a month in Inpatient Psychiatry. Typically, the ED calls our free standing lockdown psych unit for a bed for Josephine Snuffy because she is acutely psychotic and bizzare. They seem REALLY interested in getting this patieht/bother/pain off their unit. Since this is a free standing secure psych facility... and we have no lab or imaging or real ancillary emergency support aside from dialing 911 like the rest of the population... The Charge Nurses have been extensively trained to triage and screen potiential problems BEFORE they are admitted to the facility. Our mindset is... the patient is already sitting in a building full of million dollar screening, diagnostic tools and specialists that know how to use them. USE them BEFORE the patient gets to us instead of having to send a patient back out due to a oversite. We also try to avoid prescribing mind altering drug for a problem easily corrected by managing obvious organic causes. Soooo... The Charge Nurse screens the required faxed paper work, sees that the ED provider has noted several (5-6) times in their dictation that the patient has a PMH of Thyroid disease and liver disease... then the Charge Nurse calls the ED back to inqure about the missing Thyroid labs and then requests a TSH and a Ammonia Level with results called/faxed back to us PRIOR to us accepting and then transporting patient. [For the newbies... extreme Hypo/Hyperthyroidism and Hepatic encephalopathy and Urine infections can cause overt psychosis. This is easily fixable and I'd hate to put you, your mom, or grandmother on heavy duty AntiPsychotics when what was needed was Thyroid meds, Lactulose or antibiotics] Some physician then gets on the phone and starts going on and on about how in his/her opinion based upon his/her obviously superior training... and tha notion that the patient has a history of mental illness, is under 60 and therefore doesn't need a TSH or NH3 or Tox screen, or UA C&S and that they hadn't considered encephalopathy, but that their medical judgement will not be directed by a Nurse, PA, NP... blah... lah.... ah... h. The nurse then calls me and gives me the number to contact this ED/physician. I usually call, listen to the diatribe and pomposity... then calmly state... "Umm, DR... I'm NOT trying to dictate your practice of medicine... so no... I'm NOT trying to tell YOU what tests to order. So NO... YOU don't have to order the labs we asked for... but that patient will NOT be admitted here without them. Have a nice evening DOCTOR... CLICK (Dialtone). love it how about giving them a little teaching point on teh above before you hang up on them.... Link to comment Share on other sites More sharing options...
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