Best "House" Moments in Your Career?

[jmj11]

I was reading a story about perplexing and surprising (zebras) diagnoses and that made me curious about my own and your careers. What was your most memorable "House" moment  in your career, defined as a perplexing presentation that ended with a surprising diagnosis?

[ohiovolffemtp]

I was only peripherally involved in the case, but a young pregnant woman presented for the second time to the ED in one of my rural CAH's for persistent nausea and vomiting, the 2nd time with altered mental status.  Head CT revealed significant brain masses.  She was diagnosed with chorionic carcinoma that had metasized to the brain.  She'd had a previous molar pregnancy and had been advised not to get pregnant again, but did.  She was pregnant with twins, and was less than 20 weeks gestation.  She was transferred to our tertiary mother ship hospital, where gyn/onc couldn't even find a similar case anywhere in the literature.

Tragic outcome: within 2-3 days she died of a brain bleed.  She and the twins were lost.

[jmj11]

Incredible. Certainly ranks as  House moment.

[jmj11]

Headache work (my specialty) may sound mundane, but there are occasions when diagnoses are quite interesting.  In this case, I think it was around 2008, I had a 30-something year old man, Comcast cable layer, come to me with a new onset of headaches. He was not a  headachy person and this headache had been gradually building for 3-4 weeks. He saw his PCP, who sent him to a local (anti-PA) neurologist across town. She got a MRI without contrast which was normal and told him it was “stress headache” (no such thing in the International Diagnosis of Headaches) and wanted him to see a psychologist. This frustrated him and a relative (sister-in-law I think) was a migraine patient of mine and suggested that he see me.

NDPH (New Daily Persistent Headache) is a frustrating entity that we in headache disorders had to deal with all the time, usually without an identifiable underlying cause. But we always made sure that these were not secondary headaches to a treatable cause.

When I saw him, besides him never having headaches before, there were other red flags. He generally didn’t feel well, and he mentioned chills. His vital signs (including temperature) were normal and the neurologist that he had seen did order a full lab panel, which if I remember, were all normal. His exam was normal (per my memory) but I felt that something was up with him. 

I had seen an infectious disease newsletter in the previous months about a strain of cryptococcus (which was usually an opportunistic infection) in our area (Victoria, BC and Vancouver, BC, and one case in Whatcom County, the Washington county just north of us) that was infecting healthy (non-HIV) patients who work outside. As you know it often is spread by bird droppings. I got a spinal fluid sample and sent it for an India Ink stain and fungal cultures.

I remember I got a call on a Saturday morning from my SP. The lab had called him (not me) and told him the spinal fluid was positive for cryptococcus. My SP had never seen a case, not even in his residency and he said he was not getting involved with the case (don’t get me started). But he suggested I call the infectious disease department at the University of Washington. I called the ID physician on call several times, leaving messages but he never got back to me. 

To make a long story short, I went by the Sanford Guide for infectious diseases, which recommended an oral antifungal in non serious cases, which I started. But then I called down on Monday (frustrated that they would not return my calls) and made the front desk at the ID at the University of Washington squeeze my patient in for a new consult on the following day.

I saw him back for follow up weeks later. He ended up remaining on oral treatments and under the ID management. They sent their notes to my SP but never to me.  He got better and his headache resolved, but untreated cryptococcus meningitis is almost always fatal. 

I sent my notes to the local neurologist across town.
 

Edited December 31, 2022 by jmj11

[rev ronin]

I found a back pain that was actually a paraspinal abscess, but I wouldn't consider that a major House moment, because there were all sorts of red flags (acquired asplenia, EtOH habit, massive arm hematoma, patient excusing him to vomit into the sink during exam) that were pretty much "something else is going on here" unless you were intentionally trying to ignore them. That was 3y out of PA school, so I was still pretty new.

[CAAdmission]

Back in the days of paper charts in a rack, I pulled one out that said "rectal foreign body." I promptly put it back and grabbed the next one. 

My esteemed PA colleague got to extract a chicken drumstick from some guy's anus. 

[SedRate]

Case #1: The ER called on a 3-4 yo autistic kid with fever, tachycardia, leukocytosis, ankle pain, and ankle erythema. The mother provided limited history other than ankle pain and limping for maybe couple days; the development of redness prompted ER visit. XR showed soft tissue swelling. On exam, cellulitis from the ankle to distal third leg. Pt screamed during almost entire of exam, including palpation and PROM ankle, but could spontaneously wiggle toes. Skin was warm at area of cellulitis but no fluctuance, induration, open wounds. I had to coordinate sedation with anesthesia, radiology and IR for an MRI leg and ankle with possible IR aspiration if positive for joint effusion. Got a call from the radiologist that the MR leg showed acute osteomyelitis of the posterior tibia with periosteal abscess, so we booked the pt for surgery. Pod1&2, pt had much better ankle movement.

 

Case #2:

40s male with cellulitis and abscess of the proximal leg, fever, leukocytosis. Limited history. Otherwise active and "healthy" except for tobacco use. No recent trauma or history of surgery. Advanced imaging showed osteomyelitic changes of the proximal tibia. We did a surgical procedure and obtained samples, including bone. Micro came back as Cocci, so Cocci osteomyelitis. 

 

Case #3:

On my ER rotation as a student, 20s female comes in with malaise and leg rash. Otherwise healthy, nonsmoker. History obtained demonstrates she recently started a new OCP. No recent travel, trauma or illness. "They just showed up." Exam shows WDWN, pleasant female with pretibial tender erythematous nodules. Exam otherwise benign. XR benign. Dx: erythema nodosum drug reaction to OCP. 

Edited December 31, 2022 by SedRate

[kettle]

Recently had a fever chills sweats and cough pt, neg for covid, neg for flu. Something didn't seem right, good vitals but fever non responsive to antipyritics. Convinced the guy to switch him over to ER, workup stone cold normal labs cxr looked like terrible covid. Upper midwest area. So not looking viral and WBC, Pro Cal neg. Asked about travel or turning over any dirt in the woods, was told no, asked about bat exposure. Had Recently remodeled house and their were bats in the chimney. Called ID was told no prophylaxis, sent antigens for histo and strict return precautions. Came back two days later, bipap 10 days, vent 45 days with 15 days ecmo. Unfortunately was Histo..... made it almost 2 months

Edited December 31, 2022 by kettle

[Reality Check 2]

This might not be a House moment but it is a recurrent lack of common sense and listening for hoofbeats...

I keep encountering million dollar workups for cough - literally - chest CT, one had freaking sputum cultures, CXR, PFTs, etc.

Multiple are on ACE inhibitors - STOP THE ACE. 80% resolved their coughs.

The others had GERD - seriously - GERD - maybe not typical water brash and substernal burning but bad breath, sore throat and every other warning sign of GERD - obesity, late eating, reclining after eating, LES dysfunction from smoking, etoh, caffeine.

Went thru the GERD discussion, started a H2 blocker or PPI, checked back 2-3 weeks later - over 90% have resolved.

A couple needed an EGD due to Barrett's risks or refractory symptoms, risk factors.

So, maybe not a zebra or very odd - but I thought horses instead of zebras and I look like a genius.

Happy New Year!

[ventana]

Reposted from a few months ago.  Not all are zebras but some are.  
 

of note this was one week in my practice.  The 4 other docs were shaking their heads at my week.  I was exhausted.  
 

This week I am getting trampled by a herd of zerbra's... not just one (these are all patients that are my PCP patients where I am the ONLY one responsible for their care.)  I consulted outside specialists, and ran all these cases independently except brief discussions after the fact for the two MRI neuro brain cases.  

Dx                                      who was consulted

Critical subclavian stenosis with cool hand - ER and transfer out urgently

New Dx Lung CA (on LDCT on new patient that old pcp never ordered) - surgery and onc

New lymphoma Dx  (on LDCT on new patient that old pcp never ordered) - surgery, onc, cards, vascular, inpatient

Vestibular Neuroma growing into the deep brain - presented with shoulder weakness - neuro surg and ENT

Aortic Root Graft Infection from surgery 8 months ago - also new patient with vague complaints, ID, Vascular Surgeon, labs and ID follow up

Some type of corpus callosum T2 enhancing lesion on MRI - sending to neuro after lab work up

new onset schizophrenia in heavy cannabis user - MH

taking over T supplement on a patient fired by Uro 8 months ago - post testicular ca years ago...... all me....

 

this is all on top of the regular run of the mill PCP issues with DM, CHF, MH, and the likes.....  and now I am on call the entire week and weekend...  

[CAdamsPAC]

Out on an island in the Bearing Sea a 40'ish male of multiple years of Testosterone replacement therapy w/o improvement seen during a locums tour. The S/P for the village wanted me to just increase his dosage. After reviewing the pt's chart conducting good a PE along with a review of literature on hypogonadism; I sent him to be seen by Endocrine where a head CT revealed a pituitary adenoma.

 

Out in a village in the Aleutians I had a patient's family calling me after hours for their father having an "allergic reaction". Upon arrival facial/submental edema was obvious, but his tongue being elevated above his lower teeth and displaced posteriorly told true issue, Ludwig's Angina.

[trazodone]

Boerrhave's syndrome as a PA student. I ordered a "pan scan" of the chest and abdomen for a patient with chest pain with a multitude of symptoms (chest pain, abdominal pain, nausea, vomiting, AMS). For some strange reason, I ended up wheeling the patient to radiology for CT, of which I over heard the radiologist very loudly yelling "these fill in the blank ED docs just want to scan everything" to which I walked in and said, "Hi, I'm the student, I ordered the scans". 

20 minutes later the radiologist had a very different tone when he called me and described a full thickness esophageal tear with mediastinitis. There was some other complicated medical diagnoses. Patient was transferred to a tertiary care center almost immediately. 

[CAAdmission]

8 hours ago, trazodone said:

I over heard the radiologist very loudly yelling "these fill in the blank ED docs just want to scan everything"

Sounds like a moron that doesn't know job security when he sees it. 

[CAdamsPAC]

6 minutes ago, CAAdmission said:

Sounds like a moron that doesn't know job security when he sees it. 

It's not like they will take the fall when something significant is missed! We all know the official plant of Radiologist is the hedge! My final word is maybe!!!

[ventana]

26 minutes ago, CAdamsPAC said:

It's not like they will take the fall when something significant is missed! We all know the official plant of Radiologist is the hedge! My final word is maybe!!!

Don’t forget they also drum up more business by making reconditions for the next study which is always some high $$$ study.  

[ohiovolffemtp]

Radiologists should know that EM's mantra is ROBS - Rule Out Bad S@#$.

We can't just diagnose, we have to prove that symptoms aren't the sign of something potentially very bad.  Almost every other branch of medicine says "if you have new or worsening symptoms, go to the ED".

[CAdamsPAC]

I was working the ED when a 12-year-old boy was brought in after a dirt bike crash. It was a weekend and of course the small rural hospital's radiologist was at home. He was resistant to do the ABD CT that I requested and called me for justification for my order. I told him that I was worried about a spleen injury which he poo-whoed. I asked him how he would react if I did not order this study on his injured child? He reluctantly approved the study and called me to say my splenic injury  concern was disproved, and the LUQ pain was because of a fractured kidney!

 

Edited January 5, 2023 by CAdamsPAC

[ohiovolffemtp]

Just like ATLS recommends, I "trauma pan-scan" most blunt trauma patients: head & cervical w/o contrast; chest, abd, & pelvis with.  Most times negative, but this summer I found a mid thoracic burst fx on a patient thrown from a side-by-side into a rocky hill side.  He had significant pain on palpation.   I've had other expected and unexpected finds of serious injuries, some with only partially concerning mechanism and no definite findings on exam (+/- impaired mental status)

Again: ROBS.

[jmj11]

This one, another headache case, threw me a curve as well as a very good local ED physician.

A 28 year old woman came to visit my headache clinic. No prior headache history except for the past three weeks. A holocephalic headache 7-9/10, escalating in severity over time since starting. I can't remember any associated symptoms except for photophobia.

She visited the local ED twice during this time, had a head CT, and was diagnosed with a status migraine. She was given Meperidine on both visits.

Exam: Most notable to me was that her blood pressure was around 220/150 (no history of hypertension). I retook it and it eventually settled to about 200/130. I would have sent her back to the ER (wish I had as I had no IV antihypertensive drugs) but she was just there the previous night and with a similar B/P. They told her that it was related to the level of pain she was in (which I didn't believe). They did not get labs.

Most significant finding was that she had severe papilledema. She reported that during the visits to the ED, no one looked at her fundi (btw, I worked with a neurologist and I borrowed his ophthalmoscope one day when he was not at work. The clearing lady put in a drawer in my office that I never use. I discovered it almost two months later and he had never noticed it was gone. So, apparently he never does a fundoscopic exam, which is absurd).

I had seen many cases of  pseudotumor cerebri and space-occupying brain lesions, but never with this level or papilledema. I scheduled an urgent MRI and MRV that evening and a lab panel (no labs were done in the ED). I also started her on a significant dose of oral verapamil.

I called her the next day after seeing her MRI/V (which were normal). She was in a step-down unit in another hospital, where she got her labs. Turns out, her working diagnosis was 1) sudden onset of acute renal failure (cause yet to be determined), 2) associated malignant hypertension, 3) associated with increased intercranial pressure. She was getting emergent dialysis.

There is a moral to the story that you always look at fundi in a headache, especially new headache. But renal failure was not on my radar when I saw her. 

 

[CAdamsPAC]

4 minutes ago, jmj11 said:

This one, another headache case, threw me a curve as well as a very good local ED physician.

A 28 year old woman came to visit my headache clinic. No prior headache history except for the past three weeks. A holocephalic headache 7-9/10, escalating in severity over time since starting. I can't remember any associated symptoms except for photophobia.

She visited the local ED twice during this time, had a head CT, and was diagnosed with a status migraine. She was given Meperidine on both visits.

Exam: Most notable to me was that her blood pressure was around 220/150 (no history of hypertension). I retook it and it eventually settled to about 200/130. I would have sent her back to the ER (wish I had as I had no IV antihypertensive drugs) but she was just there the previous night and with a similar B/P. They told her that it was related to the level of pain she was in (which I didn't believe). They did not get labs.

Most significant finding was that she had severe papilledema. She reported that during the visits to the ED, no one looked at her fundi (btw, I worked with a neurologist and I borrowed his ophthalmoscope one day when he was not at work. The clearing lady put in a drawer in my office that I never use. I discovered it almost two months later and he had never noticed it was gone. So, apparently he never does a fundoscopic exam, which is absurd).

I had seen many cases of  pseudotumor cerebri and space-occupying brain lesions, but never with this level or papilledema. I scheduled an urgent MRI and MRV that evening and a lab panel (no labs were done in the ED). I also started her on a significant dose of oral verapamil.

I called her the next day after seeing her MRI/V (which were normal). She was in a step-down unit in another hospital, where she got her labs. Turns out, her working diagnosis was 1) sudden onset of acute renal failure (cause yet to be determined), 2) associated malignant hypertension, 3) associated with increased intercranial pressure. She was getting emergent dialysis.

There is a moral to the story that you always look at fundi in a headache, especially new headache. But renal failure was not on my radar when I saw her. 

 

C/O "Headaches" can bite you under the best of circumstances.

[ventana]

I hate headaches almost as much as vertigo/ lightheaded. 

[jmj11]

On 1/5/2023 at 6:54 PM, ventana said:

I hate headaches almost as much as vertigo/ lightheaded. 

It was funny, but I was a headache specialist at Mayo Clinic in Rochester, MN and worked (moonlighting) a fast track in a ED in a small town in Rural Minnesota. In the ED, PAs were not allowed to see headache patients (a previous lawsuit over a SDH and PA set that rule). I had to chuckle, but I didn't complain. After seeing very complex headache disorders all day, I was happy to see something else in the evening.

[sk732]

Had an older fellow come in with recurrent TIA symptoms, had been sent to a stroke clinic, was awaiting an appointment.  Had recently had CT and MRI - hadn't been told results of same so I said I'd go check...the radiologist had a panicked note on the CTA about ? Large vessel vasculitis and couldn't contact the stroke neurologist or the PCP (or the ED doc that ordered it - bit of an eye roll there)...I called infernal med, who started drooling, we scanned the rest of him and sure as shyte had aortitis - admitted.  The reason I thought of this was the day we did vasculitides in school, the House episode that night was a case of Takayasu's...and we all diagnosed it .

I'ms seeing all sorts of weirdness now - I just started working in a northern Canadian First Nations community where nothing is ever 5 minutes or is what it seems.  I'm sure I'll have something(s) new to add sometime soon.

[CAAdmission]

I've been waiting my whole career to diagnose tick paralysis. Still waiting. 

[sas5814]

I was still a student on my peds rotation and mom brought a baby in for ear infection(s) and B TMs were beet red and the kid was cranky. A very usual presentation. I picked the baby up and when I lifted his head he made a whole body tonic jerk. Set him down. Pick him up...same result.

I went and got the pediatrician and told him I thought this infant had meningitis. I got a 2 minute lecture about how unreliable meningeal signs were in infants and tasked with some reading.

He goes and examine the baby... meningitis. Air flight to children's hospital etc.

Ran into mom and baby at the PX about 4 months later. Baby lost hearing in 1 ear but was otherwise doing great.

Not exactly a "House" moment but pretty satisfying.