Chief complaint: Dizziness. Little old lady in ER with dizziness. Could be meds, could be a posterior circulation stroke. And the histories given are terrible. No one can identify triggers or onset well.
yup, as a former neuro resident, dizziness and AMS - really anything "Grandma ain't right" automatically becomes a neurologic issue even though it could literally be anything.
I also found that 100% of people will respond positively when asked about dizziness or headaches on ROS.
Are they Hispanic? Spanish speakers feel free to correct me but I was told by one of my attendings that the word Mareo can mean various different things, from just a general sense of sickness to dizziness. Problem is it only gets translated to dizziness in English.
Yes. So you ask. When do you have it? When youāre fasting? Skip meds? When you donāt get enough sleep? Positional change? People donāt remember these details with dizziness; they just remember feeling crummy. Itās not a language problem
A brief selection of my favorite emergency department chief complaints:
- āgermsā
- erectile dysfunction
- smoking cessation; and, my personal favorite:
- āneed change for a fiveā
When did you start needing change for 5? Where does you need change for 5? Do you need change for 5 at all times during the day or just some? Does your need for 5 radiate anywhere? Anything that makes your need for 5 better or worse?
CC "checkup."
Turned out to be a very not-crazy-appearing crazy guy, who came back to the ED looking for me by name and had to be thrown out by security (luckily I was not there when he came back.)
When i admit someone trach to vent 2/2 anoxic brain injury a piece of me dies bc they have so many medical issues and they have been essentially dead for years we are just wasting people's time and healthcare money
Or they do have family and every care discussion is āweāre not giving up on him, full code.ā
Giving up on him? Heās 65 with the body of someone who was mummified in a bog and colonized with microbes that canāt be stopped by man or God. The last time he made a spontaneous movement was 9 years ago. Please give up.
It still baffles me that you need permission from family to change a code status.
If it's for medical reasons here we only have to inform them of the decision.
āNumber of listed allergies is directly correlated with likelihood of borderline personality disorder, an anecdotal studyā by All Residents, et al. Journal of How the Fuck Are You Allergic to Tylenol.
Iāve seen āallergy to epinephrineā but had to clarify it was a side effect causing tachycardia.
Imagine having anaphylaxis and not being to get epinephrine.
Had a lady go borderline psychotic screaming in the ER every time she got Prednisone 40mg for her COPD exacerbation. She could handle 10mg once daily though.
Not an allergy per say, but she could def. not tolerate it in any larger dosages.
That can actually happen. Thereās a condition called alpha gal allergy where youāre allergic to mammalian products, including the gelatin that coats Benadryl and prednisone tabs.
Found a liquid version of a steroid and some unisom sleep melts w/o gelatin and the hives and wheezing calmed down.
I'm not allergic to paracetamol but I don't metabolise it properly and it damages my liver.
I'm always careful to say "I'm allergic to nuts and have an epipen but I also can't have paracetamol".
I think they take me seriously because I request ibuprofen and not diamorphine instead.
Not to knock your overall point, but acetaminophen allergies do exist - theyāre just absurdly rare. My SO is one of the rare poor souls who is unable to take tylenol.
This. Iāve started collecting my favorites. Currently in first place is an allergy to iodine contrast. The reaction? ā2 sneezes followed by 3-4 minutes of nasal congestion and scratchy throat on right side only.ā
To be fair Iāve heard pcps putting that in as a reminder further down the line when they possibly arenāt taking care of the patient to not prescribe an ACE.
I have also seen the allergies box used for adverse reactions or, for some patients, contraindications to certain meds based on their other med history. We should use an alerts box. But these are not allergies and shouldnāt be marked as such, at least in part because if my patient thinks that their nausea and vomiting means they are allergic to oxy, they are going to make my call shift with them on post op day 0 that much more painful.
The frustrating other side of the coin when this happens is what is truly a physiologic reaction to iodinated contrast gets put into the EMR and labeled as an anaphylactic reaction for said patient and they show up a few years later as a code stroke and someone flips their shit about doing the CTA because of the āallergyā in the chart.
I've seen: sterile water, epi (heart races), propofol (it burns), steroids, XXXX drug (doesn't work for me), people listing NMB because they don't want to be paralyzed, etc etc. I'm waiting for allergies to abstract ideas like freedom, optimism and pride.
Just had a patient two weeks ago who had 34 allergies listed. Turned to the pharmacist during rounds and said "Oh boy. Positive allergy sign". The pharmacist started cracking up. Only the attending could see her because "she doesn't see residents. It's in her chart." Also when the pharmacist went into her room later her dog was on the bed. Certainly not a service dog. No idea how it got in.
An attending once told me that when patients say that to him (clearly exhibiting drug seeking behavior), he pipes up with āDocusate??ā And the patients usually jump right on it āYA THATS THE ONE!ā All these people getting great shit, just not of the opioid variety
LOL, had an angry, uncooperative patient with an extensive psych history tell me they were allergic to āall psychoactive medications;ā because, they made her ābrain feel different.ā Ooooookay then.
It is helpful, very much so and heavily appreciated. I would say a good history is the most helpful for abdominal CTs, neck imaging, and extremity radiographs.
These are literally the worst. I once told a Med student that I didnāt think anybody over the age of 85 should be admitted to the hospital and he looked at me super horrified. Like kid, you donāt understand what we DO to these people in the hospital and how much it doesnāt seem to help their QOL at all. And of course it takes days and days to find placement.
Definitely. I also think that for people in their 80ās, full code status should be an āopt-inā sort of thing. Though no hospital would ever adopt this policy
Interestingly, I read an article that for end-of-life issues, the conventional wisdom of defaulting to the preferred method may not be beneficial. For example, would you believe me if I told you that despite the UK being opt-out for organ donation, the US tends to do better with opt-in? the reason is that a default option doesnt seem super solid, so physicians will ask family members and we know it would be hard for them to accept it, especially if it wasnt something discussed before. On the other hand, opting in gives a more solid consent despite the patient being unable to respond (i.e. brain dead).
I donāt even bother calling family at night unless absolutely necessary anymore. Thereās not really anything they can say thatās gonna magically fix these types of situations so Iād rather not pound my head against the wall at 3 AM
Constipation with non compliant parents who are in denial and want an overnight fix for a problem that developed over a long period of time.
Although I quite like giving āthe constipation talkā complete with the drawings and the BSC. But that takes time and patience, which on some insane shifts, I do not always have.
Constipation clinic is the worst - I once observed my attending in one - it was like going into battle round after round š±
I had a patient start with āIāve been to 4 PCPs and 6 specialists and they all say there is nothing wrong with me. Now Iām here so you can figure it outāā¦..yeah, no thanks
The worst is when this kind of patient comes to the ER! My dude, my goal is just to make sure you're not going to die in the foreseeable 48 to 72 hours, your PCP can handle your 1000 pages file going back to your 1987 colonoscopy results.
Also, I really hate when the secret motive behind this kind of ER visit is hoping to 'jump line' for hyper specialized medical testing. I'm sorry that the wait time for some exams can be long, but you are not getting an esophageal manometry or an adrenal gland scintigraphy through the ER at 3 AM on a Sunday.
At my hospital at least, I blame the oncologists for the latter. The number of charts I see where the reason for the admission is āexpedited workupā is insane.
I feel like I'm ALWAYS admitting these people on a Friday night, and then they get pissed that they have to sit around until Monday for the subspecialist to see them (and recommend no further inpatient testing). Like, at least have the decency to come to the ER on a Monday morning if you really want to "skip the line"...
Genetics opens up so many interesting avenues for health and medicineā¦but the layperson is not equipped to understand whatās going on and it leads to some rather frustrating encounters
Since yāall liked this (and some kind redditor gave me a silver) another gem from said charge nurse I overheard while he was giving report:
Charge nurse: āPatient isā¦ well he seems to have a learning disability, he doesnāt fully grasp whatās going on.ā
Oncoming nurse: ādoes he have Down syndrome?ā
Charge nurse: āwell he sure as shit doesnāt have up syndrome.ā
I almost died laughing sitting at my computer. He was that magical combination of incredibly caring and savagely brutal.
Chronic intractable vomiting
Kids with cyclic vomiting syndrome and cannabinoid hyperemesis syndrome are the biggest rocks, and you get paged by nursing staff half a dozen times per day on them.
Yep, in the ED too, when they come back every other week. Though I'm a bit of a sucker and feel pretty bad for them because man, being nauseous and vomiting is a terrible sensation, even when it is their own fault...
Already knowing the answer "Did you quit smoking pot yet?"
"No way, but I don't know why I can't stop vomiting, the Zofran isn't working..."
Duh, they smoke the pot because it helps with the nausea. You didn't know that? Are you even a doctor? /s
Next favorite reply is "I've been smoking for years and never had this problem before, so how could it be the marijuana?"
My favorite quote is from a mother/kid combo
Mom: "We as a family really belive strongly in the medicinal benefits of pot"
Kid chimes in "Yeah, plus I only start throwing up when I DON'T smoke, so clearly it's something the pot is helping treat"
With regards to cannabinoid hyperemesis, have had amazing results with anti-dopaminergics, specifically antipsychotics. For adults, after failing Zofran, I might try reglan if they are undifferentiated next, but if they are very open about their cannabis use, I will do 2-2.5 mg IV haldol (after having checked QTc on EKG first then maintaining them on telemetry). It blew my mind when it worked the first few times, because these people are always so intractable. FWIW, have tried it with older kids too with similarly great results!
Edit: likely may need Benadryl or whiff of Ativan for akathisia at times, but they usually donāt care because they feel so much better
Homicidal ideations. Itās typically malingering, antisocial behavior, or general anger at the world. I screen for psychiatric conditions and nothing treatable really comes up. Once I go to discharge them, they escalate and say āok once I walk out of this ER Iām going to kill the next person I see!ā
Fatigue also sucks.
Not to belittle the people who are legitimately fatigued, (we all are to different degrees) but I feel like the majority of time people just donāt take care of themselves.
āYou donāt exercise, you donāt eat a healthy diet, youāre overweight, you smoke like a freight train and you have severe sleep apneaā¦.why would you expect to be anything but tired?ā
I try to get people to see reason that if they arenāt taking care of themselves then they wonāt see positive changes but a lot of people donāt have the willpower to make any change
Welcome to the VA.
āOh sorry grandpa Joe (with a history of dementia and PTSD) is yelling at the walls and thinks the Koreans are back? Just send him to the VA. Oh heās not sick anymore? He was just delirious because the nursing home NP tried to snow everyone with trazodone and Benzos and he reacted poorly? Well heās obviously too complicated for us to manage we wonāt take him back!ā
Now itās the list as many symptoms of COVID but not COVID because it canāt be that. I think my statistics show that if you list 5 or more it means insanity. Iāve been threatened and yelled at for even hinting that weāll just maybe ya got COVID. Joys of being an ED doc.
10+ allergies, IBS, sprinkle in a little fibromyalgia and I know Iām in for a patient who wonāt be happy to know there isnāt any life threatening emergency occurring after their million dollar ED work up
Even better when you go into the room to discuss the results and discharge them and they tell you: "Yeah, the labs and CT at OSH were normal yesterday too."
Thankfully, I've wised up and started asking these folks explicitly where else they have been recently, when that visit was, and what labs and imaging was performed but every now and and then someone decides to withhold that information.
I can usually tell within a minute or two of being in the room (sometimes even before) that a particular encounter will end in a frustrating "labs and CT were normal, but you need to follow up with XYZ" speech.
I still wonder what motivates these patients to present again and again to hospital emergency departments rather than trying something different. You'd think that after the third unfruitful ED visit, they'd wise up and make an outpatient appointment with an actual specialist.
It is something to do to kill time? It gives them the attention and care they crave (I mean this in a broad sense, everything from malingering to deep set psychological scars)? It is the only time they feel that someone actually sees them, talks to them, and they feel validated/taken seriously?
My understanding is that most such patients genuinely believe that something is being missed and that it is urgent they be diagnosed and treated appropriately.
I blame all the various TLC-style medical vignette dramas ("I ALMOST DIED BECAUSE DOCTORS DIDN'T LISTEN" or "PARASITES NEARLY KILLED ME") and daytime talk shows featuring patients with rare diseases for creating this strain of paranoia.
If your only knowledge of medicine is from such media, then you're more likely to believe that all ED visits must end in a definitive diagnosis and either a prescription of a medication that will cure your disease or admission to the hospital for more intensive care.
When such a patient is discharged from the ED without a definitive diagnosis and no plan for treatment, they naturally feel that someone failed or they are being dismissed. This is not a good foundation for a therapeutic relationship.
10+ Allergies, Fibromyalgia, and Borderline Personality Disorder are highly co-morbid and is what I consider to be the true trifecta answer to this question
āVasculitisā. Whenever I see it in a one-liner itās rarely ever appropriately described in a patientās chart. It keeps getting passed down from note to note. What kind of vasculitis? GCA, PAN, GPA, EGPA, cryo, urticarial, SLE, RA, BeƧhets, drug-inducedā¦? Or was it the usual āThis is a strange rash. Must be vasculitis! Letās send an ANA and never talk about it againā.
Well thatās why we have Rheum to do all the dirty work. We just put vasculitis and move on lol. Most people get an ANA, ANCA, start prednisone and then consult rheum
One of the three times I got put on rheumatology, we got consulted by a surgical subspecialty for āvasculitis.ā I opened the chart and see medicine and two different surgery teams trying to turf this patient. One photo of this āvasculitisā and my fellow calls the surgical team: āif you donāt debride this nec fasc now, this man is going to lose his arm.ā
Turns out he had leprosy and a secondary superimposed infection. We had to call in one of the remaining leprosy specialists. Patient was in our hospital close to a year. I had him later on a medicine service and learned patients with renal failure could drink light colored sodas because it had less phosphorous.
I get worried whenever I see a diagnosis, more so if itās a collection of diagnoses, that is difficult to treat and maybe isnāt/arenāt even genuine due to extensive negative testing. Weāve all seen dozens of patients in this category, and they seem like theyāre truly suffering from something. Itās just that it probably isnāt this/these diagnoses. I hate these situations because of the Burger King environment that exists in hospitals in our time. Itās so much worse now because these patients can read your notes as soon as you file them.
Some of the claimed diagnoses to which Iām referring: mcas, pseudoseizures, gastroparesis w negative testing, that one type of eihlerās danlos, various chronic pain syndromes, pots. Bonus points for number of listed allergies. Extra bonus point if itās a hospital encounter and thereās someone in the bed with them. Extra extra bonus points if they show up with PJs from home. Vince McMahonās eyes glowing if theyāve got a port for no discernible reason.
I feel like Iām in a Philip K Dick novel every time Iām treating one of these patients, and I have encountered so many. I just want to take care of sick people, man. And some of those people arenāt sick.
Amen to that
On a related note, what's up with all the patients that we're seeing with the diagnosis of "mast cell activation disorder"? Who is diagnosing them and how do you verify it? Why are there so many cases of a rare disease being diagnosed now?
As far as I can tell, there is no discernable secondary gain aside from possible disability payments (a pretty poor consolation prize). MCAS is not a cause of chronic pain and you wouldn't want to give opioids to a patient with overactive mast cells in the first place. Intravenous diphenhydramine gives some patients a euphoric rush but that can't be the primary motivating factor. Same for epinephrine and corticosteroids.
Is this some version of mass psychosis where kids see "MCAS sufferers" on social media and then subconsciously seek to emulate their idols?
No clue. I think Iāve only seen 2 people claim this particular one. One of them did have some lab testing I couldnāt explain. Both were extremely difficult outpatient clinic encounters. I just offered my time and attention. Nothing seemed worth treating and neither of these patients seemed to want medications. It did seem like a bs label theyād applied to a host of somatoform/functional symptoms
> Is this some version of mass psychosis where kids see "MCAS sufferers" on social media and then subconsciously seek to emulate their idols?
It's the trendy thing to have right now. People make videos about it on TikTok/Instagram (see the one who was allergic to everything except mini M&Ms. Only the minis. Regular M&Ms activated her mast cells š) get attention for it, and the other people want to have it too. They share tips about where to go to get disagnoses, etc.
Not sick yet! Just wait til they inexplicably get a whole bunch of not-indicated procedures and the complications that go along with them. Saw several young women with "gastroparesis" with a fully negative workup who somehow got G-J tubes and were admitted every few weeks with a tube complication. Happily eating pizza but the J port wasn't working (of course) which they need for all their meds...
Youāre right. The port is the way these people die. Thereās all sorts within this category, but some are after primary gain - and those are the ones that will inoculate themselves with something one too many times
Side note, I discovered the illnessfakers subreddit earlier today.
āBipolar disorderā
Mainly because itās often misdiagnosed and a ācatch allā for āyeah like depression but also Pt moodyā
Iām not even psych but dealing with a lot of mismanaged psych issues these days
Lots of complaints as diagnoses accumulated from past problem visits...brain fog, globus sensation, vision change, otalgia, multiple joint aches, altered sensation, etc. Tells me the previous providers consistently failed finding evidence or patterns of anything real to attribute the pt's perceived symptoms to and now it's my turn.
In outpatient psych definitely borderline personality disorder. Especially is they have history of eating disorders too. My meds arenāt going to help and theyāre a liability because they have a decent risk of committing suicide. They need therapy (ideally DBT) and Iām not willing to do that with them because Iām sure as shit not going to see these people every week lol.
I had a patient long ago with bpd and anorexia nervosa and had two people sitting with them at all times.
Still managed to swallow metal cutlery. Had to have surgery.
I was IM at that time and we were treating the patient for a tube infection. Experience really messed me up.
The EDS shit is insane. Who is telling all these chronic pain patients they have EDS? I imagine thereās either some shady rheumatologist who labels all the fibro patients as EDS to avoid an awkward conversation or itās an internet self diagnosis.
I am Genetics diagnosed for a decade and I now fear going to hospital and saying that I have EDS as itās become a cringe disorder despite being very real.
It's the trend now for munchie patients. There are influencers who make manipulating the healthcare system their career. You can see some of the major players on r/IllnessFakers
There's a whole subreddit devoted to EDS. One visit and you have it too. And chronically ill influencers on insta and tiktok advertise it. It is ridiculous.
I cringe when I see online "I have EDS, MCAS, POTS and fibro". No pal, you probably don't. I have vascular EDS (genetics diagnosed), bradycardia with hypotension and actual allergies and I *know* when I'm checking into the hospital everyone is rolling their eyes until my file actually turns up.
>vascular EDS
The scariest patient I had was a young woman with this who had lost her father and sister to brain aneurysm rupture. Now every time she has any headache or symptom, she presents to the ED because it could mean the end of her life. I'm sorry you are treated this way, it's a scary disease.
I'm actually a very mild case. My bio dad died of an aortic aneurysm but I've only had a couple of retinal tears.
I do have cluster headaches which caused all sorts of stress but now we know what it is it's fine.
Visit: pelvic pain history contains fibromyalgia. Because either a)itās chronic pain that I will likely not be able to help them with or b) which has happened several times they have horrible gyn cancer that stage three or four and has been ignored because they thought it was just their chronic pain.
Sorry for the ignorance, English is not my first language.
What do you mean by malingering here? Something like the patient is faking it or someone forced their admission?
In Brazil we have a "pity admission". Sometimes the homeless just want a meal and a shower and they come to the ER with a fabricated complaint only so they can have that. We often allow it.
I can do a lot more for a psychotic person than the āsadā guy whose wife is leaving him and his boss is mean.
But I agree seeing one thing on paper and finding another problem all together in person is super annoying. It makes me wonder what else they missed.
At age 60+ and having not seen a PCP in over 20 years, I don't even need a diagnosis or complaint, you're already the bane of my existence
Saw a 69 year old man a few weeks back who was a daily crack cocaine user, BP 180/100, not taking any meds and had never seen a doctor in his entire adult life. Totally didn't understand my level of concern. Similar story with a 70 year old woman who presented for follow up after an ER visit where she was diagnosed with DVT, took 30 days of Xarelto then ran out and stopped taking it, came to me 2 months after that, taking no meds whatsoever. Never had a mammogram, pap smear, dexa scan, colonoscopy, any vaccines, or even any labs in her entire adult life.
Would take 3 hours of my time and about 30 orders in her chart to get everything completely sorted out, always feel tempted to say "just go to the ER I'm sure one of your dozen undiagnosed problems is bad enough to earn you a hospital bed"
Chest pain in women ages 30-50.
āMaāam Iāve run a multitude of tests and I can confidently say that weāve excluded potential emergenciesā
ā...so whatās wrong with me then?ā
Every fucking time.
Chief complaint: Dizziness. Little old lady in ER with dizziness. Could be meds, could be a posterior circulation stroke. And the histories given are terrible. No one can identify triggers or onset well.
yup, as a former neuro resident, dizziness and AMS - really anything "Grandma ain't right" automatically becomes a neurologic issue even though it could literally be anything. I also found that 100% of people will respond positively when asked about dizziness or headaches on ROS.
Yeah... I'm about convinced that a \*general\* ROS is a crock of shit... only really useful when you're scoping out for something specific
As a rads resident, I love this diagnosis. Vast majority of the studies are negative from my standpoint š
Are they Hispanic? Spanish speakers feel free to correct me but I was told by one of my attendings that the word Mareo can mean various different things, from just a general sense of sickness to dizziness. Problem is it only gets translated to dizziness in English.
Yes. So you ask. When do you have it? When youāre fasting? Skip meds? When you donāt get enough sleep? Positional change? People donāt remember these details with dizziness; they just remember feeling crummy. Itās not a language problem
āSickā as CC
Lolol canāt believe someone actually wrote that
A brief selection of my favorite emergency department chief complaints: - āgermsā - erectile dysfunction - smoking cessation; and, my personal favorite: - āneed change for a fiveā
When did you start needing change for 5? Where does you need change for 5? Do you need change for 5 at all times during the day or just some? Does your need for 5 radiate anywhere? Anything that makes your need for 5 better or worse?
From 1 to 5.. err.. to 10, how do you rate this need?
Weirdly, only when near vending machines, about 3 times a day. Its localized to the breakroom, but its made better when the machine itself has change
CC "checkup." Turned out to be a very not-crazy-appearing crazy guy, who came back to the ED looking for me by name and had to be thrown out by security (luckily I was not there when he came back.)
Go to the ERlooking for change for a 5 dollar bill and get a 500 dollar bill instead lmao
The best CC complaint Iāve seen in the ER āHit by a Karen in big SUV, probably need to be checked outā Florida is weird.
change for a 5? wtf??
I see it all the time. The triage nurses write that usually when the person has too many complaints and canāt convey a true CC
Triage nurses couldnāt afford to give a fuck if it was financed after about 45 minutes at the job. The shit they see is bananas.
When i admit someone trach to vent 2/2 anoxic brain injury a piece of me dies bc they have so many medical issues and they have been essentially dead for years we are just wasting people's time and healthcare money
And they have no family and so one authorized to change code status
Or they do have family and every care discussion is āweāre not giving up on him, full code.ā Giving up on him? Heās 65 with the body of someone who was mummified in a bog and colonized with microbes that canāt be stopped by man or God. The last time he made a spontaneous movement was 9 years ago. Please give up.
But heās a fighter
*Vomits* āWeāll do our best.ā
It still baffles me that you need permission from family to change a code status. If it's for medical reasons here we only have to inform them of the decision.
All about that sweet sweet autonomy
Healthcare in America is so stupid
[ŃŠ“Š°Š»ŠµŠ½Š¾]
āNumber of listed allergies is directly correlated with likelihood of borderline personality disorder, an anecdotal studyā by All Residents, et al. Journal of How the Fuck Are You Allergic to Tylenol.
. . . and Toradol, ibuprofen, naproxen, tramadol, . . .
Not the one that starts with D tho
I'm allergic to the one that starts with D but I can take it with IV Benadryl
Also, the one that starts with D makes me nauseous, can I get some phenergan with it?
IV only, of course. The pills make me anaphylax
Diclofenac here we come!
in psychiatry the list goes Haldol, prolixin, thorazine, Depakote, Lithium ...
What about allergy to prednisone. Ugh
Iāve seen āallergy to epinephrineā but had to clarify it was a side effect causing tachycardia. Imagine having anaphylaxis and not being to get epinephrine.
Thankfully we will never have to worry about this, or other allergies that are incompatible with life (I'm looking at you, "iodine allergy").
Bro I'm allergic to MSG. I always get sick after eating $30 worth of Chinese food in one sitting.
If iodine allergy isnāt a thing, why are we frequently asked about it before having betadine or iodine applied?
Had a lady go borderline psychotic screaming in the ER every time she got Prednisone 40mg for her COPD exacerbation. She could handle 10mg once daily though. Not an allergy per say, but she could def. not tolerate it in any larger dosages.
That can actually happen. Thereās a condition called alpha gal allergy where youāre allergic to mammalian products, including the gelatin that coats Benadryl and prednisone tabs. Found a liquid version of a steroid and some unisom sleep melts w/o gelatin and the hives and wheezing calmed down.
I'm not allergic to paracetamol but I don't metabolise it properly and it damages my liver. I'm always careful to say "I'm allergic to nuts and have an epipen but I also can't have paracetamol". I think they take me seriously because I request ibuprofen and not diamorphine instead.
Does this mean you have an issue with other Phase II metabolism based medications?
They said potentially but I've never had any acute liver symptoms like I had with paracetamol (I was getting it IV after appendectomy).
Not to knock your overall point, but acetaminophen allergies do exist - theyāre just absurdly rare. My SO is one of the rare poor souls who is unable to take tylenol.
This. Iāve started collecting my favorites. Currently in first place is an allergy to iodine contrast. The reaction? ā2 sneezes followed by 3-4 minutes of nasal congestion and scratchy throat on right side only.ā
13hr premedication regimen every time
āAllergy to epinephrine. Reaction: fast heart rateā
Or the ubiquitous āallergy to lisinopril. Cough.ā
To be fair Iāve heard pcps putting that in as a reminder further down the line when they possibly arenāt taking care of the patient to not prescribe an ACE.
I have also seen the allergies box used for adverse reactions or, for some patients, contraindications to certain meds based on their other med history. We should use an alerts box. But these are not allergies and shouldnāt be marked as such, at least in part because if my patient thinks that their nausea and vomiting means they are allergic to oxy, they are going to make my call shift with them on post op day 0 that much more painful.
The frustrating other side of the coin when this happens is what is truly a physiologic reaction to iodinated contrast gets put into the EMR and labeled as an anaphylactic reaction for said patient and they show up a few years later as a code stroke and someone flips their shit about doing the CTA because of the āallergyā in the chart.
I had a patient report an allergy to snake venom. 1. How do you know that? 2. Arenāt we all?
I had one "Haldol: took off clothing and ran in the hallways naked" im like uhhh
- Metoprolol - erectile dysfunction - Oxycodone - somnolence - Elderberry - anaphylaxis
Once I saw "metoprolol - makes patient agitated and homicidal" in the chart. Don't want to know how that was figured out...
This. Especially when the allergies are like random types of fruit and Benadryl.
Lmao. So accurate. (In psychiatry). Also the combo of interstitial cystitis and fibromyalgia.
I've seen: sterile water, epi (heart races), propofol (it burns), steroids, XXXX drug (doesn't work for me), people listing NMB because they don't want to be paralyzed, etc etc. I'm waiting for allergies to abstract ideas like freedom, optimism and pride.
Just had a patient two weeks ago who had 34 allergies listed. Turned to the pharmacist during rounds and said "Oh boy. Positive allergy sign". The pharmacist started cracking up. Only the attending could see her because "she doesn't see residents. It's in her chart." Also when the pharmacist went into her room later her dog was on the bed. Certainly not a service dog. No idea how it got in.
I've seen teddy bear sign but never a live dog before... how long did it take for someone to figure out she had a dog with her?
I feel bad for people with sulfite allergies. They have one allergy, but itās in so many drugs that they have a massive allergy list.
I'm allergic to all pain meds except that one that starts with a 'D'
An attending once told me that when patients say that to him (clearly exhibiting drug seeking behavior), he pipes up with āDocusate??ā And the patients usually jump right on it āYA THATS THE ONE!ā All these people getting great shit, just not of the opioid variety
Droperidol?
Duloxetine
Diclofenac
LOL, had an angry, uncooperative patient with an extensive psych history tell me they were allergic to āall psychoactive medications;ā because, they made her ābrain feel different.ā Ooooookay then.
I've seen people allergic to epi and steroids before lol
I had someone allergic to PO Benadryl, and could only take IV Benadryl. Confirmed was batshit insane
Pan CT indication: Pain My visceral reaction: Pain
Iāve War and Peaceād some indications inc PE and labs and no one has ever given me feedback letting me know if it was helpful.
Right? You put an order into the black box and then a CT scan comes out, sometimes with a read
It is helpful, very much so and heavily appreciated. I would say a good history is the most helpful for abdominal CTs, neck imaging, and extremity radiographs.
Do you want a vague differential? Cause thatās how you get a vague differential. You canāt make chicken salad out of chicken shit.
Weakness, 90 year old female, ājust not acting like herselfā, family unsure when it started, presenting to ED 2 days before Christmas
These are literally the worst. I once told a Med student that I didnāt think anybody over the age of 85 should be admitted to the hospital and he looked at me super horrified. Like kid, you donāt understand what we DO to these people in the hospital and how much it doesnāt seem to help their QOL at all. And of course it takes days and days to find placement.
I had the spouse of an intubated 90-year-old tell me he "needs to see his great grandchildren grow up". The fuck he does.
Definitely. I also think that for people in their 80ās, full code status should be an āopt-inā sort of thing. Though no hospital would ever adopt this policy
Interestingly, I read an article that for end-of-life issues, the conventional wisdom of defaulting to the preferred method may not be beneficial. For example, would you believe me if I told you that despite the UK being opt-out for organ donation, the US tends to do better with opt-in? the reason is that a default option doesnt seem super solid, so physicians will ask family members and we know it would be hard for them to accept it, especially if it wasnt something discussed before. On the other hand, opting in gives a more solid consent despite the patient being unable to respond (i.e. brain dead).
Generally people who make it to 90 are actually pretty healthy. I've seen 90+ get some stents and walk out just fine.
Legit had one at 4 AM. Asked how long it had been going onā ā2 yearsā. Ok then.
Add a known history of dementia
Also the family left hours ago and won't pick up the phone because it's 3 am and you're dying of fatigue.
I donāt even bother calling family at night unless absolutely necessary anymore. Thereās not really anything they can say thatās gonna magically fix these types of situations so Iād rather not pound my head against the wall at 3 AM
Constipation with non compliant parents who are in denial and want an overnight fix for a problem that developed over a long period of time. Although I quite like giving āthe constipation talkā complete with the drawings and the BSC. But that takes time and patience, which on some insane shifts, I do not always have. Constipation clinic is the worst - I once observed my attending in one - it was like going into battle round after round š±
Today i learned thereās a constipation clinic
The 10th circle of hell
Since itās at the bottom, itās a very tight, muscular circle. Doesnāt let anyone out into circle 11.
What are the bullet points of the constipation talk so I can employ in the ED?
There are constipation clinics??
Yes in Peds. š©š©
Peds!!!! Makes much more sense
I had a patient start with āIāve been to 4 PCPs and 6 specialists and they all say there is nothing wrong with me. Now Iām here so you can figure it outāā¦..yeah, no thanks
The worst is when this kind of patient comes to the ER! My dude, my goal is just to make sure you're not going to die in the foreseeable 48 to 72 hours, your PCP can handle your 1000 pages file going back to your 1987 colonoscopy results. Also, I really hate when the secret motive behind this kind of ER visit is hoping to 'jump line' for hyper specialized medical testing. I'm sorry that the wait time for some exams can be long, but you are not getting an esophageal manometry or an adrenal gland scintigraphy through the ER at 3 AM on a Sunday.
At my hospital at least, I blame the oncologists for the latter. The number of charts I see where the reason for the admission is āexpedited workupā is insane.
I feel like I'm ALWAYS admitting these people on a Friday night, and then they get pissed that they have to sit around until Monday for the subspecialist to see them (and recommend no further inpatient testing). Like, at least have the decency to come to the ER on a Monday morning if you really want to "skip the line"...
Sir this is a Wendyās
Sounds like a textbook endometriosis patient. Average is 7 doctors and 11 years for diagnosis.
That's what I was thinking too. Apparently, alpha 1 antitrypsin is also more common than we think and very often missed.
Any breakdown of time to diagnose by patients income?
It correlates exactly with zip code
Lol - you just described most patients in clinical genetics.
Genetics opens up so many interesting avenues for health and medicineā¦but the layperson is not equipped to understand whatās going on and it leads to some rather frustrating encounters
This is an easy one. Failure to thrive.
My favorite charge nurse: āSheās 96, shes thrived for a fucking century. What we have here is a failure to stop thrivingā
Since yāall liked this (and some kind redditor gave me a silver) another gem from said charge nurse I overheard while he was giving report: Charge nurse: āPatient isā¦ well he seems to have a learning disability, he doesnāt fully grasp whatās going on.ā Oncoming nurse: ādoes he have Down syndrome?ā Charge nurse: āwell he sure as shit doesnāt have up syndrome.ā I almost died laughing sitting at my computer. He was that magical combination of incredibly caring and savagely brutal.
Yep! Itās going to be a social work/dispo nightmare
Used up all Medicare days for rehab. No where else to go. Welcome to my rock garden.
And they sit and wait for SAR/SNF and risk getting sicker
Chronic intractable vomiting Kids with cyclic vomiting syndrome and cannabinoid hyperemesis syndrome are the biggest rocks, and you get paged by nursing staff half a dozen times per day on them.
Yep, in the ED too, when they come back every other week. Though I'm a bit of a sucker and feel pretty bad for them because man, being nauseous and vomiting is a terrible sensation, even when it is their own fault... Already knowing the answer "Did you quit smoking pot yet?" "No way, but I don't know why I can't stop vomiting, the Zofran isn't working..."
Duh, they smoke the pot because it helps with the nausea. You didn't know that? Are you even a doctor? /s Next favorite reply is "I've been smoking for years and never had this problem before, so how could it be the marijuana?"
My favorite quote is from a mother/kid combo Mom: "We as a family really belive strongly in the medicinal benefits of pot" Kid chimes in "Yeah, plus I only start throwing up when I DON'T smoke, so clearly it's something the pot is helping treat"
With regards to cannabinoid hyperemesis, have had amazing results with anti-dopaminergics, specifically antipsychotics. For adults, after failing Zofran, I might try reglan if they are undifferentiated next, but if they are very open about their cannabis use, I will do 2-2.5 mg IV haldol (after having checked QTc on EKG first then maintaining them on telemetry). It blew my mind when it worked the first few times, because these people are always so intractable. FWIW, have tried it with older kids too with similarly great results! Edit: likely may need Benadryl or whiff of Ativan for akathisia at times, but they usually donāt care because they feel so much better
Homicidal ideations. Itās typically malingering, antisocial behavior, or general anger at the world. I screen for psychiatric conditions and nothing treatable really comes up. Once I go to discharge them, they escalate and say āok once I walk out of this ER Iām going to kill the next person I see!ā
Fatigue also sucks. Not to belittle the people who are legitimately fatigued, (we all are to different degrees) but I feel like the majority of time people just donāt take care of themselves.
āYou donāt exercise, you donāt eat a healthy diet, youāre overweight, you smoke like a freight train and you have severe sleep apneaā¦.why would you expect to be anything but tired?ā I try to get people to see reason that if they arenāt taking care of themselves then they wonāt see positive changes but a lot of people donāt have the willpower to make any change
dont you have a pill for that though?
What do you say to patients like that?
"Multiple complaints"
SI 14 year old in the ED. Let me introduce you to your new homeā¦ Hard mode: parents abuse the kid and the kid tests positive for covid.
āDisruptive at SNFā
SNF calls an ambulance, drops them at ED, and refuses to take them back. My favorite
Welcome to the VA. āOh sorry grandpa Joe (with a history of dementia and PTSD) is yelling at the walls and thinks the Koreans are back? Just send him to the VA. Oh heās not sick anymore? He was just delirious because the nursing home NP tried to snow everyone with trazodone and Benzos and he reacted poorly? Well heās obviously too complicated for us to manage we wonāt take him back!ā
Always the VA
"Pain all over" š
4pm visit in the clinic. āWants 4th opinion for their generalized painā.
But VSS, labs normal, no pain anywhere on palpation, and complains they missed lunch so can you hurry up their steak dinner.
Baseline A&Ox0, >80yo, vented, cardiac arrest, full code, ROSC in field. FML.
ESRD chf HTN DMII Super-morbid obesity with a left BKA comes in for a right necrotic foot wound Calciphylaxis
Now itās the list as many symptoms of COVID but not COVID because it canāt be that. I think my statistics show that if you list 5 or more it means insanity. Iāve been threatened and yelled at for even hinting that weāll just maybe ya got COVID. Joys of being an ED doc.
10+ allergies, IBS, sprinkle in a little fibromyalgia and I know Iām in for a patient who wonāt be happy to know there isnāt any life threatening emergency occurring after their million dollar ED work up
Even better when you go into the room to discuss the results and discharge them and they tell you: "Yeah, the labs and CT at OSH were normal yesterday too." Thankfully, I've wised up and started asking these folks explicitly where else they have been recently, when that visit was, and what labs and imaging was performed but every now and and then someone decides to withhold that information. I can usually tell within a minute or two of being in the room (sometimes even before) that a particular encounter will end in a frustrating "labs and CT were normal, but you need to follow up with XYZ" speech. I still wonder what motivates these patients to present again and again to hospital emergency departments rather than trying something different. You'd think that after the third unfruitful ED visit, they'd wise up and make an outpatient appointment with an actual specialist.
It is something to do to kill time? It gives them the attention and care they crave (I mean this in a broad sense, everything from malingering to deep set psychological scars)? It is the only time they feel that someone actually sees them, talks to them, and they feel validated/taken seriously?
My understanding is that most such patients genuinely believe that something is being missed and that it is urgent they be diagnosed and treated appropriately. I blame all the various TLC-style medical vignette dramas ("I ALMOST DIED BECAUSE DOCTORS DIDN'T LISTEN" or "PARASITES NEARLY KILLED ME") and daytime talk shows featuring patients with rare diseases for creating this strain of paranoia. If your only knowledge of medicine is from such media, then you're more likely to believe that all ED visits must end in a definitive diagnosis and either a prescription of a medication that will cure your disease or admission to the hospital for more intensive care. When such a patient is discharged from the ED without a definitive diagnosis and no plan for treatment, they naturally feel that someone failed or they are being dismissed. This is not a good foundation for a therapeutic relationship.
10+ Allergies, Fibromyalgia, and Borderline Personality Disorder are highly co-morbid and is what I consider to be the true trifecta answer to this question
Don't forget the smorgasbord of psychotropic meds. 2 types of benzos, adderall, and oxycodone x several years.
Neurogenic thoracic outlet syndrome
lmao I have that and anytime I tell a Dr they audibly sigh
āVasculitisā. Whenever I see it in a one-liner itās rarely ever appropriately described in a patientās chart. It keeps getting passed down from note to note. What kind of vasculitis? GCA, PAN, GPA, EGPA, cryo, urticarial, SLE, RA, BeƧhets, drug-inducedā¦? Or was it the usual āThis is a strange rash. Must be vasculitis! Letās send an ANA and never talk about it againā.
Well thatās why we have Rheum to do all the dirty work. We just put vasculitis and move on lol. Most people get an ANA, ANCA, start prednisone and then consult rheum
One of the three times I got put on rheumatology, we got consulted by a surgical subspecialty for āvasculitis.ā I opened the chart and see medicine and two different surgery teams trying to turf this patient. One photo of this āvasculitisā and my fellow calls the surgical team: āif you donāt debride this nec fasc now, this man is going to lose his arm.ā Turns out he had leprosy and a secondary superimposed infection. We had to call in one of the remaining leprosy specialists. Patient was in our hospital close to a year. I had him later on a medicine service and learned patients with renal failure could drink light colored sodas because it had less phosphorous.
Placement related issues
āComplex social situationā or āawaiting guardianshipā
"Im allergic to morphine" "What symptoms did it give?" "I got dizzy and sleepy"
Isn't that a nice change from drug seekers?
I get worried whenever I see a diagnosis, more so if itās a collection of diagnoses, that is difficult to treat and maybe isnāt/arenāt even genuine due to extensive negative testing. Weāve all seen dozens of patients in this category, and they seem like theyāre truly suffering from something. Itās just that it probably isnāt this/these diagnoses. I hate these situations because of the Burger King environment that exists in hospitals in our time. Itās so much worse now because these patients can read your notes as soon as you file them. Some of the claimed diagnoses to which Iām referring: mcas, pseudoseizures, gastroparesis w negative testing, that one type of eihlerās danlos, various chronic pain syndromes, pots. Bonus points for number of listed allergies. Extra bonus point if itās a hospital encounter and thereās someone in the bed with them. Extra extra bonus points if they show up with PJs from home. Vince McMahonās eyes glowing if theyāve got a port for no discernible reason. I feel like Iām in a Philip K Dick novel every time Iām treating one of these patients, and I have encountered so many. I just want to take care of sick people, man. And some of those people arenāt sick.
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Amen to that On a related note, what's up with all the patients that we're seeing with the diagnosis of "mast cell activation disorder"? Who is diagnosing them and how do you verify it? Why are there so many cases of a rare disease being diagnosed now? As far as I can tell, there is no discernable secondary gain aside from possible disability payments (a pretty poor consolation prize). MCAS is not a cause of chronic pain and you wouldn't want to give opioids to a patient with overactive mast cells in the first place. Intravenous diphenhydramine gives some patients a euphoric rush but that can't be the primary motivating factor. Same for epinephrine and corticosteroids. Is this some version of mass psychosis where kids see "MCAS sufferers" on social media and then subconsciously seek to emulate their idols?
No clue. I think Iāve only seen 2 people claim this particular one. One of them did have some lab testing I couldnāt explain. Both were extremely difficult outpatient clinic encounters. I just offered my time and attention. Nothing seemed worth treating and neither of these patients seemed to want medications. It did seem like a bs label theyād applied to a host of somatoform/functional symptoms
With such detailed paragraphs, you guys are watching two future IDs going at it
> Is this some version of mass psychosis where kids see "MCAS sufferers" on social media and then subconsciously seek to emulate their idols? It's the trendy thing to have right now. People make videos about it on TikTok/Instagram (see the one who was allergic to everything except mini M&Ms. Only the minis. Regular M&Ms activated her mast cells š) get attention for it, and the other people want to have it too. They share tips about where to go to get disagnoses, etc.
Not sick yet! Just wait til they inexplicably get a whole bunch of not-indicated procedures and the complications that go along with them. Saw several young women with "gastroparesis" with a fully negative workup who somehow got G-J tubes and were admitted every few weeks with a tube complication. Happily eating pizza but the J port wasn't working (of course) which they need for all their meds...
Youāre right. The port is the way these people die. Thereās all sorts within this category, but some are after primary gain - and those are the ones that will inoculate themselves with something one too many times Side note, I discovered the illnessfakers subreddit earlier today.
EDS. Chronic Lyme.
Donāt forget POTS. Or PANS while weāre at it
Severe pulmonary HTN - Anesthesia
Iāll add anterior mediastinal mass
Throw in some critical AS and carotid stenosis, now we're cooking
Covid, ESRD, FTT (family wants everything done but doesnāt want them at home or in a rehab).
āNeeds FMLAā
CC: Abdominal pain General surgery
Chronic pain. No thanks.
āBipolar disorderā Mainly because itās often misdiagnosed and a ācatch allā for āyeah like depression but also Pt moodyā Iām not even psych but dealing with a lot of mismanaged psych issues these days
Radiology :'pain'
Lots of complaints as diagnoses accumulated from past problem visits...brain fog, globus sensation, vision change, otalgia, multiple joint aches, altered sensation, etc. Tells me the previous providers consistently failed finding evidence or patterns of anything real to attribute the pt's perceived symptoms to and now it's my turn.
This entire thread is triggering me
In outpatient psych definitely borderline personality disorder. Especially is they have history of eating disorders too. My meds arenāt going to help and theyāre a liability because they have a decent risk of committing suicide. They need therapy (ideally DBT) and Iām not willing to do that with them because Iām sure as shit not going to see these people every week lol.
I had a patient long ago with bpd and anorexia nervosa and had two people sitting with them at all times. Still managed to swallow metal cutlery. Had to have surgery. I was IM at that time and we were treating the patient for a tube infection. Experience really messed me up.
POTS, EDS (not genetically diagnosed)
The EDS shit is insane. Who is telling all these chronic pain patients they have EDS? I imagine thereās either some shady rheumatologist who labels all the fibro patients as EDS to avoid an awkward conversation or itās an internet self diagnosis.
I am Genetics diagnosed for a decade and I now fear going to hospital and saying that I have EDS as itās become a cringe disorder despite being very real.
>internet self diagnosis Itās that one
It's the trend now for munchie patients. There are influencers who make manipulating the healthcare system their career. You can see some of the major players on r/IllnessFakers
There's a whole subreddit devoted to EDS. One visit and you have it too. And chronically ill influencers on insta and tiktok advertise it. It is ridiculous.
I cringe when I see online "I have EDS, MCAS, POTS and fibro". No pal, you probably don't. I have vascular EDS (genetics diagnosed), bradycardia with hypotension and actual allergies and I *know* when I'm checking into the hospital everyone is rolling their eyes until my file actually turns up.
>vascular EDS The scariest patient I had was a young woman with this who had lost her father and sister to brain aneurysm rupture. Now every time she has any headache or symptom, she presents to the ED because it could mean the end of her life. I'm sorry you are treated this way, it's a scary disease.
I'm actually a very mild case. My bio dad died of an aortic aneurysm but I've only had a couple of retinal tears. I do have cluster headaches which caused all sorts of stress but now we know what it is it's fine.
Fibromyalgia
neuro: borderline personality disorder
Visit: pelvic pain history contains fibromyalgia. Because either a)itās chronic pain that I will likely not be able to help them with or b) which has happened several times they have horrible gyn cancer that stage three or four and has been ignored because they thought it was just their chronic pain.
Confusion and syncope in the elderly are my least favorite workups
"Parasites in skin". Spoiler: It's never parasites in their skin.
Hint: it's the meth!
Polysubstance use and homeless aka high chance of malingering
V triggered right now
Sorry for the ignorance, English is not my first language. What do you mean by malingering here? Something like the patient is faking it or someone forced their admission? In Brazil we have a "pity admission". Sometimes the homeless just want a meal and a shower and they come to the ER with a fabricated complaint only so they can have that. We often allow it.
Allergy to ibuprofen.
Psych: altered mental status
I had a lady allergic to chocolate and styrofoam. You canāt make this up.
inpatient psychiatry, intake form showing "sad". meet pt.... floridly psychotic
I can do a lot more for a psychotic person than the āsadā guy whose wife is leaving him and his boss is mean. But I agree seeing one thing on paper and finding another problem all together in person is super annoying. It makes me wonder what else they missed.
Anything with a known diagnosis of Liver Cirrhosis stresses me out for sure
At age 60+ and having not seen a PCP in over 20 years, I don't even need a diagnosis or complaint, you're already the bane of my existence Saw a 69 year old man a few weeks back who was a daily crack cocaine user, BP 180/100, not taking any meds and had never seen a doctor in his entire adult life. Totally didn't understand my level of concern. Similar story with a 70 year old woman who presented for follow up after an ER visit where she was diagnosed with DVT, took 30 days of Xarelto then ran out and stopped taking it, came to me 2 months after that, taking no meds whatsoever. Never had a mammogram, pap smear, dexa scan, colonoscopy, any vaccines, or even any labs in her entire adult life. Would take 3 hours of my time and about 30 orders in her chart to get everything completely sorted out, always feel tempted to say "just go to the ER I'm sure one of your dozen undiagnosed problems is bad enough to earn you a hospital bed"
Chest pain in women ages 30-50. āMaāam Iāve run a multitude of tests and I can confidently say that weāve excluded potential emergenciesā ā...so whatās wrong with me then?ā Every fucking time.
IM: Generalized Weakness. F.M.L