Things I Have Noticed
1) If you present to the ER with chief complaints of headache AND chest pain, then you are most likely suffering from an anxiety disorder. You get bonus points if you are a youngish female. Caveat: this assumes that there is no fever, that the blood pressure is reasonably normal, and that no nitroglycerine has been given. Certainly patients with chest pain who are given nitroglycerine often complain of headache afterwards. And patients with the flu usually hurt all over and it's obvious they are sick. These are not the patients I am considering. Typically, patients with heart attacks don't complain of headaches, and patients with intracerebral catastrophes don't complain of chest pain.
Don't worry, I'm still going to do the CT scans, ECG, cardiac monitoring, and blood tests anyway. I'll probably even admit you. Maybe you've got Lyme Disease. Probably not. Expect a humongous bill when you are discharged with nothing. It costs a lot to make sure your anxiety disorder isn't something worse, and either of your complaints MIGHT be something serious. However, in my experience, the presence of chest pain and headache together is almost diagnostic of anxiety disorder without any tests at all. Unfortunately the lawyers have trained us to order a gazillion tests and overadmit to cover our butts.
Interestingly, studies show that performing MRI scans on patients with chronic headaches is cost effective (due to decreased utilization of subsequent resources), but it is cheaper to empirically treat patients (with proton pump inhibitors) who are diagnosed with noncardiac chest pain rather than working them up further for gastrointestinal causes.
2) You cannot feel when your blood pressure goes up, and it is not causing your headache. In fact, patients with high blood pressure are less likely to get headaches. And if you are worried about a blood pressure of 160/90, then it is likely your anxiety that is driving up your blood pressure. You've probably been taking your BP every 5-10 minutes, and you will bring me several handwritten pages of the strikingly similar BP readings. Which brings me to #3....
3) A patient who has multiple somatic complaints and brings a meticulously detailed litany of their often nonphysiologic symptoms is batshit crazy. There is nothing physically wrong with that person. But she too will undergo the expensive megaworkup. And she will be shocked...SHOCKED!... that all her tests came back normal. "Then why do I feel this way?" she will ask. When I suggest that her symptoms are likely psychosomatic or anxiety-related, she will storm out of the ED in anger, not even willing to consider the possibility that she might have a psychiatric condition. But she does. As soon as she pulls out THE LIST, I know immediately.
Labels: patients
posted by scalpel at 12:06 AM
18 Comments:
Thank you, I've been dying for a doctor to confirm that you can't feel your blood presure go up!
I'm off to settle an argument with an attention seeking moron...
Also the more "numb and tingly" you feel the less and less likely you are to have anything I care about.
"Interestingly, studies show that performing MRI scans on patients with chronic headaches is cost effective"
But don't forget top do the Lumbar Puncture. MRI alone is not 100% protective against the lawyers.
It's a long story but a while ago, I was working with a charming man in his 80s who meticulously recorded his BP 6 times a day. He turned out to be a retired professor of cardio-thoracic medicine. For his own case-study reasons, he documented the effect of his medications and various lifestyle changes.
So, it was interesting to see the changes in his BP and pulse rate when he practised some breathing techniques and changed some sleeping habits (amongst other changes). After consultation with his cardiac consultant (whom he trained), he has now stopped his BP medications. He is continuing to monitor his BP etc. and to have regular ECGs.
I take this as an indication that surgeons never really lose their curiosity as to what makes the body tick or how it operates.
Regards - Shinga
Love the batshit crazy pic--too funny.
I have a related vignette. I once had a bad reaction to vicodin and an antibiotic.
After a night hallucinating that I was dead with tentacles bursting from my stomach (and glow-in-the-dark arms, can't forget those), I started to have chest pain and the radiating down the left arm thing. Called my doc, but they were busy and said go to the ER.
Instead of the ER, I just discontinued everything and went to see the doc the next day. The further away I got from the last dose, the better I felt and the smaller the tentacles got.
The heart attack thing was a reaction to the antibiotic. We switched out antibiotics, I dumped the vicodin and took motrin like I had wanted to in the beginning (that wasn't my first bad acid trip courtesy of prescription narcotics, but the doc thought I would need them. I am now much more insistent about not taking Vicodin or any of its batshit crazy relatives).
I was very close to being one of your young women with heart attack symptoms. Instead, I stayed home and tried to french braid my tentacles (so they'd fit better in my coffin).
M
Honestly, it is not safe to disregard chest pain, and I recommend that anyone of any age with chest pain go to the ER for evaluation. I would never inteentionally make a patient feel bad about coming in for an evaluation of any problem that concerns them. Most people are relieved to learn that their symptoms do not represent a dangerous condition. A few people, oddly, get quite angry that we didn't find anything wrong with them.
Scalpel, maybe they got angry with you because they were embarrassed.
Batshit crazy? I don't remember that in the DSM-4, but I think your example of batshit crazy should check herself into a hospital:-)
MJ
Oh, don't worry about me and my medical gauntlet. I just thought it was a funny story. I'll never forget those tentacles. :)
M
Scalpel, maybe they got angry with you because they were embarrassed.
Anon, nobody should feel embarrassed about their decision to seek care in the ED. I have never personally ridiculed a patient. If someone is concerned about any problem whatsoever, I feel it is my duty and privilege to help them as best I can. Part of that help includes educating them about how to manage such cases at home.
What people occasionally fail to understand is that my colleagues and I in the emergency department are there to evaluate emergency conditions. Once we have determined that your condition is not going to cause you immediate or proximate harm, then we really don't have to offer any treatment or advice at all. We can discharge you from triage with no tests whatsoever, and offer only a referral without even prescribing medication.
Of course, most of us don't do that, because we went into medicine to help people. Basically, people get angry when their expectations are not met. They were expecting to get seen in an hour, and it took 4 hours. Or they were expecting to get seen within 4 hours and it took 8 hours. Nobody expects to wait 8 hours, but it happens all the time.
After waiting 8 hours to finally see a doctor, who out of compassion overtreats the patient's zit by prescribing antibiotics but spends only a minute or two with him, that patient might ask "That's it? I waited 8 hours for that?"
What the heck did he expect, for me to call in an Infectious disease specialist at 3 am? It's a freaking zit! That's why he had to wait 8 hours.
Well, heck. I've had a headache this week and was fretting about whether or not my blood pressure was up. But now I'm wondering if I'm batshit crazy. (Oh well, at least I don't have chest pain.... )
Have you found that the ones that are largely apologetic to bother you with their problems are usually the ones that actually need medical attention?
anon 1225,
I will speak for myself. But yes, often those having the whopping MI or bones sticking out of their skin often are apologetic about taking my time. While literally coding someone and doing CPR, the bedside neighbor (who can see what is going on) often will be yelling because he didn't get jelly with his toast.
Oh, I didn't mean to suggest that you were rude to the patient I was just thinking that most people probably would not receive the news that their problem was psych related very easily, no matter how kindly it was presented.
I was told (rudely) that my problems were post partum depression ...that was the phrase she used in the letter to my PCP ...to me, she told me to 'stop being a baby about being a new mother'.
It took me 2 years to fully seek a real diagnosis (and by then, I was in the ER unable to walk, barely able to talk, and unable to lift my hands to even feed myself)... for Myasthenia Gravis.
Oddly enough ... my frustration wasn't that she thought it was psychological and not physical (yes, she should be ashamed of the way she said it to me) ... but that I WANTED HER TO BE RIGHT.
My fear of going and strongly persuing a 'real' diagnosis ... was that I would find out that some rest, maybe counseling wouldn't fix it and I'd be sick forever.
Now the WAY she told me ...that's a whole nother kettle of fish.
The more I read your blog and those of the other ER docs, the more I wish I'd been more circumspect with my response to those 2 am calls. You guys do have a tough job, even if the hours are sort of predictable. Not sure I'd have been able to handle it with grace at all times.
All jobs are tough in their own way. Working in retail, fast food restaurants, customer service...all have to deal with the big rush of angry and demanding customers, limited respect, relatively low income, and lots of weekends and holidays.
I'm happy I am able to have a career that gives me the satisfaction of helping people, a generous income, and a modicum of respect. We as physicians are truly blessed, and any complaints I might have about my situation are really pretty silly in the whole scheme of things.
But it is difficult making decisions through the fog of inadequate sleep, there is no doubt about it.
Batshit crazy? Ha! I love that term.
Personally, though, I hate to be labeled as anxious before the tests are back! It wasn't in an ER, but I had post-op complications (SOB, chest pain) that the surgeon tried to say was just anxiety. I was actually told to just take some Ativan. I think only because I acted practically batshit crazy did the doc order a CT scan (probably just to not have to deal with me anymore) that determined I did not have anxiety after all!
Post a Comment
<< Home