I’m not interested in challenges. I just like things to be straightforward. Sick people need to stay in the hospital, not sick people have to go home. It’s the tweeners, the patients I’m not sure what to do with, that cause me the most grief. For instance:
A hispanic lady in her 50s comes in with a chief complaint of “thinks her mucinex made her sick.” Her vital signs are normal. She been to our ER maybe six times in the past two years, for various minor complaints.
She’s spanish-speaking only so her history gets filtered through an interpreter. Apparently she developed a cough over the last couple of days or so. She started taking an old prescription form of mucinex. That night she woke up feeling sick, she assumed from the medicine.
“What do you mean sick?” The first thing she says is half of her face is numb and feels heavy. Lots of other things too, her hands feel swollen, she has a headache, she’s had chills and sweats, she’s been throwing up, she’s had trouble breathing, she feels dizzy.
Ok enough, really people less is more. Back to the first thing you said. Are you sure it’s not your entire face? (no). Has this ever happened to you before? (no). Does it still feel numb now eight hours later? (yes).
The only medical problem she lists is high blood pressure. She doesn’t smoke. No previous strokes or mini-strokes. She’s not on a daily aspirin.
She looks a little older than stated age but otherwise well. Her face works normally. Except for decreased sensation to light touch on half of her face her neurologic exam is completely normal.
She gets a broad workup and it’s normal, including head CT, chest xray, urinalysis, blood work, and an EKG. I go back and see her a couple of hours later and she’s still complaining of half her face feeling numb. And so I start arguing with myself.
This lady seems fine other than being a little dramatic and crazy. Maybe I should send her home.
Then again, I’ve had to talk to her through the interpreter. How good of a feel for her do I really have? Maybe I should admit her.
She says she’s had migraine headaches before — never any associated neurologic stuff but maybe this is just a first time complicated migraine. Maybe I’ll send her home.
It’s hard to send a patient home with an ongoing neurologic defecit, even as sketchy as this one. Maybe I’ll admit her.
This lady’s been here a bunch of times before and it’s always been nothing. She has a million complaints. Just send her home.
What if she comes back two days later with half her face drooping down? I should probably just admit her.
I’ve already given the hospitalist four admissions in three hours. He won’t like this one bit. Maybe she can just follow up.
Except she’s medicaid and doesn’t even know the name of her doctor and there’s no way she’s getting timely follow up. Why are you even sweating it this much? Just bring her in.
What would you do?
Update: For anyone interested, I put what I did in the comments section.
February 16, 2008 at 10:46 am
Whenever I’ve got a patient with a “grossly positive review of systems,” I know I’m in trouble unless I can find something focal on physical exam or maybe labs.
(I’m heading to Guatemala in a month, and one of the reasons is to get fluent so I can feel a bit more confident with my Spanish-only patients and pick up some of their nuances!)
February 16, 2008 at 11:04 am
Maybe this is helpful, maybe this wont be.. but this is from a patients perspective.
Unfortunately I am one of those bizarre cases. I have been shunted from specialist to specialist and they can’t seem to find exactly what it is that is wrong. I have been met with really horrible attitudes from some doctors, and total compassion from others.
My medical history is extremely complex and in the last 18 months out of the blue I have started having all of these bizarre symptoms that you can see visably, and are physically impossible to make up. My hands shake. My fingers shake independantly of each other in ways that I couldnt voluntarily make them do. I have seizures, but they cant figure out why. EEG normal. My muscles shake so bad that when I am lying in bed, my bed shakes like its an earthquake and my husband can feel it. My muscles ache and joints ache like I have been beat up with a bat every single day.
I have an original diagnosis of IIH. Now they say I have BFS as well. I have had 27 Surgeries in 10 years for my IIH, and my brain slipped due to lack of spinal fluid from being over shunted. There could be scar tissue there or anything. Who knows. It doesnt explain the seizures. It didnt prevent them taking away my drivers license though!
Doctors can’t possibly know everything. At the end of the day, you have to do the best you can with the tools you have. Alot of it has to come not only from what you have learned in school, but what you have learned in life.
Remember to be kind…. even to your church window patients with hundreds of little panes….
February 16, 2008 at 11:53 am
Graham — picking up some spanish will be more valuable than all your 4th year rotations combined. The docs in the group that speak spanish are faster, don’t tie up other staff with translations, get the history directly, etc.
Plus it’s freaking Guatemala! By the time you get to 4th year you deserve some time to hang out on the beach.
February 16, 2008 at 1:17 pm
Well, since we have 24-hour MRI (at my residency program) and we like to use it, we’d MRI/MRA her before (probably) sending her home. But we MRI almost anyone w/ a neuro complaint, unless they’re a slam-dunk Admission and can wait.
February 16, 2008 at 1:22 pm
Based on the information here, she goes home. I don’t get excited by isolated sensory neurologic deficits Ideally, she should get a follow-up with her doc, if she has one, and if I’m feeling particularly diligent I might chat with a neurologist to set up an outpatient consultation and MRI prior.
But you’re telling the story, so I know there’ll be a good punchline. I can’t wait.
February 16, 2008 at 4:04 pm
A lot of these middle-aged female numbnesses, complete with every other possible symptom, get cured with an ativan and an authoritative explanation of how it is designed for that kind of numbness.
February 16, 2008 at 5:15 pm
I would bring her in. If I face much resistnace for the admission I would atleast keep her for obs in the ED until morning to get her a neurology consult.
P.S. Any history of travel?
February 16, 2008 at 6:09 pm
I would do what you did, start her on asa and call neuro to arrange followup… In Canada we do not have the bed space to admit these people (non motor RINDs/CVAs) plus with her positive ROS it is hard to know what is real
February 16, 2008 at 7:44 pm
From the hospitalist perspective:
What exactly do you want me to do with this patient? We get at least one a day:
MRI, MRA, neuro consult, carotid dopplers, 24 hours of tele, echo, blood cultures (negative in 3 days), UA, urine culture.
We won’t find anything and she’ll feel better in 3 or 4 days. She’ll go home on aspirin which she may or may not take.
These patients are the reason there are no beds and the ER has 7 really sick holdovers…
February 17, 2008 at 9:55 am
Dear Docs Who Want To Learn Spanish:
Go to Costa Rica. I love Guatemala I do, but it’s not where I would go to learn Spanish. Also, any coastal areas in Guatemala require travel to really, really rural areas and those bus drivers aren’t immune to driving off the side of mountains. Every time I go to Antigua, every. time. a bus has taken a nose dive off a cliff. I’m not sure if the bandidos are still active or not, but last I heard the odds of gringos being raped and pillaged were still pretty high. I love Guatemala I really do, I spent lots of time there as a child, but it’s not where I would send someone unfamiliar with the sociopolitical dynamics of the region to fend for themselves.
Coast Rica is better in my opinion. First, you can drink the water and won’t lose any time to Montezuma’s Revenge. Two, the accent is just as clear and beautiful as that of Guatemala. Three, they do have beaches that are accessible and radiant.
Although Guatemala has beautiful folkart, probably the richest tradition in Central America. Oh and the fresh tortillas are to die for. Just add a little butter and salt. Costa Rica is a bit more modern and urban, less jarring in terms of cultureshock.
M
February 17, 2008 at 12:28 pm
oo. Sounds like yet another reason why there is not enough funding for health care. Patients who are lonely and just need some attention suck up doctor time for real emergencies … yet we’ve all heard stories about people being sent home (because someone just thinks their drunk) and dying of a stroke or aneurism. What did you end up doing?
February 17, 2008 at 4:12 pm
did she end up with bell’s palsy or really no way to know what happened after she was sent away…
February 17, 2008 at 10:20 pm
The diagnosis is very clear. It is a variant of “status hispanicus” or AKA “hispanic panic” characterized by variations of numbness, heaviness, and dizziness.
This is a condition caused by percieved neglect from her family and boredom of staying home all day. By going to the hospital she gets some attention and her “sickness” is validated by all the tests that are performed to check her out.
She should go home. If you have more than 5 chief complaints no emergency medical condition exists.
February 18, 2008 at 12:03 am
I’m with those whose call is that this woman is somaticizing, and needs to be sent home, where the root problem can be more effectively addressed. In your area, is there any way to arrange for follow-up by a public health nurse who will go to the home? A monthly visit, if at all possible, might just keep the patient from being an ER regular.
I get where Nurse K is coming from, but as a psych nurse, I have to disagree that giving a benzo – under the guise of medication made specifically for her problem – is the thing to do. If she’d had a psych consult while in the ER with a conclusive diagnosis of major anxiety disorder, sure. Otherwise, we’ve seen too many problems crop up from giving antianxiety meds that supposedly treat a specific physical disorder.
February 18, 2008 at 1:28 am
This isn’t remotely helpful, but hey, you don’t know me so what do I care, right? I am SO GLAD I’m an artist, not a doctor. When I make stuff up, people are pleased.
February 18, 2008 at 11:18 am
If you admit someone when you think they might be a little overdramatic, aren’t you reinforcing to them that they should come in with every little thing? Isn’t it sort of like giving someone antibiotics because you can’t get them to understand that they are not useful in a virus? I’m not a doctor, so I have no idea of course and I know if you missed something it would be bad for you and for them. I guess that is why it is such a fine line for you to walk in figuring this out. This is why I bring cookies for my doctors all the time…my little way of showing them that I know they go through a lot and I appreciate what they do for me.
February 18, 2008 at 4:14 pm
In the end, I decided it all added up to a whole lot of nothing and sent her home on a baby aspirin a day and “close” followup.
I don’t know how she did, this happened a few months ago and she hasn’t been back since. I’d call to see how she’s doing but everyone with her was spanish speaking only.
I don’t like these patients. Even though I’m virtually certain it’s nothing it just takes one of them to come back with a stroke for me to feel terrible and be screwed. In fact, it just takes one to happen to have a stroke, unrelated to the symptoms she was having during the visit, for me to be screwed.
I just do my best to practice sensible medicine, and keep my fingers crossed that I’m not unlucky enough to have a bad outcome.
Sorry to anyone expecting a zebra punchline!
February 18, 2008 at 9:58 pm
You’re a doctor, not a magician – you can’t be expected to spot and prevent every possible ailment.
Although I expect that argument doesn’t work very well with Lawyers, huh?
February 19, 2008 at 8:01 am
Remember, you’re not treating the labs- you’re treating the lawyer!
February 19, 2008 at 3:33 pm
As you probably know, I’m a send-homer, and she would definitely be going home if it were me. That doesn’t mean that there won’t eventually be a wolf, but if you don’t really suspect that she’s had a stroke (not a TIA if her symptoms haven’t gone away), then you aren’t doing her a favor by putting her in the hospital.
February 20, 2008 at 5:59 am
ED where i used to work, that sort of patient was bound to be sent home. a whole range of seemingly unrelated symptoms (especially the ‘numbness’ type) and no real hard signs with a negative CT… i mean, some of those patients wouldnt have scored the CT even. it’d be a real challenge finding a team that’d admit her too.