Maybe this will become a series, like the ones over at NY Emergency Medicine
. If you win, you get a cookie.
Or, like with White Coat Rants' "You Play Doctor
," perhaps not.
A middle-aged woman is brought to the ER by her doting husband, complaining of chest pain. It's her fifth visit of the year so far. Previous workups during those visits have included 3 rapid influenza screens, 2 CT scans of the brain, 1 CT scan of the chest, several X-rays, and multiple series of blood tests, including cardiac enzymes and liver panels... all of which were entirely normal. And yet her pain was so severe that she required repetitive doses of Dilaudid. Her pain was never really relieved, she was just made sleepy enough to not protest too much when she was discharged each time.
Although her chief complaint is "chest pain," as the interview progresses it becomes clear that she really hurts all over. Her headache is intolerable, her chest feels like it is being torn apart, her back is aching horribly, and she claims that she is too weak to get out of bed. She says that she has been vomiting for days, and she "can't keep anything down."
She's dressed in a nightgown and robe at 2 pm, and other than her depressed affect and subjective generalized weakness her examination is pretty unremarkable. Her vital signs are normal, her mucous membranes are moist, and her abdomen is surprisingly nontender. She never actually vomits in the ER, she just feels nauseated and refuses to drink water. Her husband comes up to the nurses' station and asks "aren't you going to do anything about her pain?"
Her diagnosis is probably:
3) Lyme disease
4) Churg-Strauss syndrome
5) Polymyalgia Rheumatica
8) None of the above
Her workup for this visit should include:
1) Repeat CT scans of the brain and chest, and maybe the abdomen.
2) Forget the CT scans, let's do some MRIs.
3) Repeat the comprehensive lab panel, and let's add a lyme titer, lupus panel, and urine for porphyrins.
4) spinal tap
5) Psych consult
6) Admission for further workup and pain control
7) None of the above
I lied about the cookie, by the way. There are no winners in this scenario.
Labels: ER, medical, patients