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Let's hear the best med student diagnoses. We do provide something to patient care on occasion other than playing the role of note monkey!
I diagnosed a guy that had been having panic attacks for a year, was continually presenting for chest pain and had multiple cardiac workups as well as seen several specialists who just couldn't find anything wrong with him. Each time he had an episode, his description would resemble an MI - yet when the tests were done, there was nothing. He was a young guy (~30) and otherwise healthy.
He came in to my FM preceptors clinic and I listened to his story - and it was remarkable how clearly these attacks were secondary to anxiety. It was nearly textbook.
Yet he had undergone multiple workups and no one else had diagnosed it as such. Made me wonder if any of the physicians involved had taken the time to listen to the guys story, or if it was just a matter of hearing "chest pain" and then doing a bunch of tests.
a) Everyone knows it's anxiety; it's just that no one wants to deal with it.
b) If you walk into a docs office or ED and say "chest pain", you get the big-time workup. Everyone is too scared of liability to blow it off.
Let's hear the best med student diagnoses. We do provide something to patient care on occasion other than playing the role of note monkey!
45 yo female presents to ER c/o "swollen veins", leg pain, and her chronic pancreatitis pain. Patient has known, stable, polycystic kidney disease. She has presented to this ER 3x in the past two months with complaints of "pancreatitis pain", treated, and released. Primary reason, she presents to ER is leg pain secondary the swollen veins and that she is fearful that they might "bust". Over the past 12 mos she has been worked up from mast to stern for GI disorder with no findings other than a high lipase and signs/symptoms of pancreatitis. She has been treated at a total of 4 different hospital ERs, and admitted occassionally for treatment of pancreatitis. Today, lipase is normal. Physical findings: mid-epigastric TTP, RUQ TTP, superficial thrombophlebitis R leg 2 locations. Pancreatic Cancer is very high on student's differential. Talks resident into ordering CA19-9. Days later 19-9 comes back >30K. Previous CT study indicated lesion on liver. Lesion on liver is biopsied consistent with pancreatic cancer.
a)I got the impression people had thought of anxiety - as in they had probably dismissed his claim as psychosomatic after the initial event, but panic attacks and simple anxiety are distinct entities and panic attacks are very treatable.
b)Yes, I get why he got the workup. I don't get why he was worked up 20+ times and sent to several specialists.
It's a rule out.. You know, make the list of things that it could possibly be. Eliminate the most serious things from the list..
Even when a known panic attack hits the ER and says they have chest pain, they always get the EKG etc. You're screwed if you don't...
I had several psych diagnoses when on FP. One dude broke down crying describing all of the tests he had gone through to diagnose his somatizations.
A classmate had the best I've heard of: Noticed the triad of HTN, hypo K, and hypernatremia in a pregnant pt. Told the OB resident at rounds the pt needed a workup and surgery consult. Resident laughed, and replaced K. Repeat x 3 days, until my classmate could get the attending alone. Consult ensued, resident shamed, student exonerated.
thanks, I was puzzling over it tooHyperaldosteronism, aka Conn's Syndrome. I had to look it up. Didn't recognize that triad..
thanks, I was puzzling over it too
Conn's. At least, that's how it shows up in your usual daily Chem 7's and vitals. The aldo level confirms it.what's that diagnosis?
I had one woman who had the same story and I told her that she likely had an anxiety disorder. I educated her on what that meant, what treatments were available, and she seemed agreeable. It was a busy clinic day, so after I presented the case to my resident, he went in with her while I went to see pt #2.Yes, psych patients have heart attacks too, but I have to agree with lilnoelle--20 negative workups and NO ONE took the time to do psychoeducation about panic attacks?
lilnoelle--I hope you're thinking of coming over to join us on the Dark Side.
It works both ways. I had a tearful patient who came in to the outpatient clinic complaining of stress and anxiety, and who almost didn't even bother to mention the chest tightness radiating to the left arm with exertion until I asked about chest pain offhand during the ROS. My attending and I personally walked that patient over to the ED, over the patient's vehement protests. Sure enough, cardiac enzymes were elevated. Pt was hospitalized.Yes, psych patients have heart attacks too, but I have to agree with lilnoelle--20 negative workups and NO ONE took the time to do psychoeducation about panic attacks?
Finally I can actually say that I saved a life directly, which felt awesome knowing that I really helped. Had been sent by my resident on medicine wards to go admit a young lady in her early 20s in the ER who had been complaining of some SOB and lightheadedness, along with tingling in her feet. She had + asthma history and was presumed to be having an exacerbation. That's all I was told - sounded like a straightforward admission for a third year student early on in the school year...
Before I go see her I looked up all her records online and find one ER note from 2 years earlier mentioning she had myasthenia gravis...
so I go to the ER to see her and find her laying obtunded and minimally responsive, with what appeared to be BL bell's palsy. Take a look at her labs and see ABG with pCO2 of 55 from 30 minutes prior, most other things WNL. According to nurse at the time the patient was perfectly ok apparently. So I frantically page my resident like 5x in a row and no response. I tell the nurse and she was basically no help....saying she was going to check on her in a minute. no one was doing jack. Wait, she says. So after no response within two minutes, I went to the omnicell (i knew one of the nurse's code), got an ABG kit, and redrew an ABG myself on the patient - rushed it to the upstairs lab and had them run it on the spot - pCO2 was 140. I remembered the words of one of our directors of medicine - "rapidly rising pCO2 = impending respiratory failure." Told the nurse and THEN she panics, so I paged the anesthesiologist on ER call to bring the crash cart. Within a few minutes they're intubating the lady...so by the time my resident actually got there, the whole thing was done and she was on the vent being supported. Turns out she had MG induced respiratory failure....another 5 minutes and she probably would have died, right there, on the ER bed supposedly on close observation by the nurses for her asthma complication...
Nah, she would have died. It was near the beginning of third year, I'll be damned if I knew how to intubate anyone back then. And no, I didn't get honors...bastards...
Wow, tough crowd. Good catch though. Where was the ED doc through all of this?
I found that one of her meds, oxaprozin (an NSAID) cross-reacted with the drug screen and produced a false positive. With that, after talking with her family doc, we correctly attributed the AMS and prior episodes to early onset dementia.