Make That Diagnosis
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:
1) Lupus
2) Porphyria
3) Lyme disease
4) Churg-Strauss syndrome
5) Polymyalgia Rheumatica
6) Migraine
7) Fibromyalgia
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.
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:
1) Lupus
2) Porphyria
3) Lyme disease
4) Churg-Strauss syndrome
5) Polymyalgia Rheumatica
6) Migraine
7) Fibromyalgia
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.
posted by scalpel at 9:09 AM
47 Comments:
"she just feels nauseated and refuses to drink water"
Maybe she's got Rabies? Ok, just kidding.
I suppose these are for doctor types and not layperson types to guess at?
My vote is dissection. And she makes my spidey sense nervous.
Assuming that she's afebrile, has a nice normal sinus rhythm, and good vitals, I'd probably vote for the psych consult. Seems like she's been worked up pretty well in the past. In a robe at 2pm...sounds depressed. What does her primary say? Is she on pain meds chronically? This is the sort of case that frustrates ER folks. Sigh...
Exactly.
999/1000 of these patients are kooks. But she has a dramatic presentation with numerous complaints which might be something serious.
But how far do we dig?
The easiest thing to do would be just to admit her, but nobody wants to admit a patient like this. And there isn't even a clear indication for admission. She's not really vomiting, she doesn't appear short of breath, her oxygenation is normal, and she really can walk with encouragement.
Psych won't see her unless she's a danger to herself or others, and she isn't inclined to accept a psychiatric diagnosis anyway. So the cycle of "dope her up and send her out" is perpetuated.
ok, my guess is Porphyria. I would do the comprehensive lab panel, lyme titer, lupus panel, and urine for porphyrins. Let's admit for further workup and pain control.
Fibromyalgia and Psych Consult ;-)
Lyme disease?
I really like cookies.
How about a thyroid panel?
I'll give it a shot.
My instinct is Fibro, but I don't think you'd go through all the trouble to post that case.
She's a little too old for the presentation of SLE, right? And I don't remember cramming "GI issues" into my brain for that notecard...
I think maybe the time table is too long for lyme disease. Porphyria makes sense. Has she ever had a seizure??
No allergies, asthma, etc, so I'd put Churg-Strauss on the lower part of the list.
My guess is (after fibromyalgia): Polymyalgia Rhumatica.
I'd do 6 and 3 on the list of "workups."
~MS1
You said there are no winners in this scenario, so my guess would be the lethal options. Not Lyme, unless it's in her brain already, but she doesn't have the rash, and good luck getting it to show up on a lab test.
I'd say not the Churg-Strauss because like the pp said, she doesn't have acute onset asthma. The pain is in the wrong places for the polymyalgia isn't it? Fibromyialgia isn't lethal, and neither are psych problems.
I don't know what it is, but it ain't those. In my uneducated layperson opinion.
I don't know what she has, but I think it's a mixture of fibromyalgia, anxiety, and depression.
There are no winners because even if my diagnosis is correct, she won't be happy with it, and the treatments are palliative at best and usually unsatisfactory in terms of providing relief.
The interesting conundrum is this: when do you stop working these patients up for rare and exotic conditions and just assign them a wastebasket fibromyalgia/mystery pain diagnosis?
You can't just admit stable patients for "workups" anymore, and primary care physicians usually aren't inclined to chase down zebras. A couple of patients like this can really wreak havoc on a clinic schedule.
So they end up in the ER, where we find that they don't really have an emergency condition, and so we send them back home.
Frustrating for all.
I always screen for adrenal insufficiency, a random cortisol, possibly a cosyntropin stimulation test, B12 deficiency and thyroid, and a sed rate in folks who have goofy, funny unexplained symptoms, but look healthy.
Sometimes I'll order an RPR to screen for syphilis.
After that, you're talking about the less common stuff goofy like autoimmune. Screen for ANA, RF, heavy metal screens, porphyria,
Ultimately, it's usually, "nothing structural", can't find a physiological explanation.
Almost always, there is a component of mental "imbalance", whether it is depression, anxiety, because sick people depressed, and depressed people feel sick. The two go hand in hand.
Actually scalpel I'd disagree with the fibro diagnosis, I think we hand it out far too easily. Unless she's got trigger point pain I'd just give her some Dilaudid to gork her out, and tell her to come back if she dies or something.
Here's my personal perspective with chronic fatigue and fibromyialgia. While in college, I got EBV twice and even when recovered from that I was tired etc. I had a doctor dx me with fibromyialgia and chronic fatigue. The man then insisted that you couldn't have those and not be depressed so he convinced me to try antidipressents. They made me depressed and every time I'd talk to him about how I was feeling he'd up the dosage until I started to have overdose reactions. Finally so that I wouldn't off myself, and to preserve my sanity, I decided that the doc was crazy and I slowly weaned myself off. It was like the sun came out from behind the clouds. We moved to Arizona shortly after that and I lost all of my previous issues. I don't know if it was the reduction of stress because I wasn't in school anymore, or if it was that we moved from a place with heavy air pollution to a place with no air pollution. I suspect the pollution. We have recently moved back, and I have started to feel more fatigued. My personal therapy is going to be to exercise more and get out in the sun a lot, because I think the Arizona sun helped.
"I always screen for adrenal insufficiency, a random cortisol, possibly a cosyntropin stimulation test, B12 deficiency and thyroid, and a sed rate in folks who have goofy, funny unexplained symptoms, but look healthy."
I was thinking Addison's, either primary or secondary. I suffered from secondary Addison's for a while and all of those symptoms are suspicious.
You people with your psych recommendations; you suck.
Here is my fear though. When I first started going to the doctor before my thyroid cancer was diagnosed, I had just had a baby, and my main complaint was that I was so tired all the time. I had 4 small (a newborn, two 3 year olds and a just turned 6 year old) children, so obviously it was pointed out to me that I *should* be tired, but then the low fever began.
I think most of my symptoms could EASILY have been brushed away as depression, in fact I suggested that to my doctor and asked if he could just treat me as if I had depression and see what happened. I was desperate to feel better. Luckily he finally felt the stupid nodule and got all the testing started, and luckily I am not a doctor because with my experience, I would have a hard time ever being positive that someone had nothing wrong with them and stopping the testing.
Has the woman ever had her TSH and T4 and all that tested? How about the anti thyroid antibodies? I know almost nothing about anything medical so I have no idea if any of this would help the diagnosis, obviously.
Hypothyroidism and adrenal insufficiency can cause a variety of vague, nonspecific symptoms, and certainly some features of her presentation could possibly be explained by those conditions. The severe chest pains and headaches, however, don't really fit.
And when someone says they've been vomiting for several days, unable to keep anything down, yet they never vomit even once in the ED and they have no clinical or laboratory evidence of dehydration or electrolyte disturbances...it calls their entire story into question.
Rare metabolic diseases in the absence of vital sign abnormalities or life-threatening electrolyte disturbances can generally be safely worked up as an outpatient anyway.
"The symptoms of Addison's disease develop insidiously, and it may take some time to be recognized. The most common symptoms are fatigue, muscle weakness, weight loss, vomiting, diarrhea, headache, sweating, changes in mood and personality and joint and muscle pains. Some have marked cravings for salt or salty foods due to the urinary losses of sodium.[2]
Clinical signs
On examination, the following may be noticed:[2]
Low blood pressure that falls further when standing (orthostatic hypotension)
Some of my main signs were headache and chest pain.
You really have make an effort to get a cortisol reading on patients to diagnose this problem. It isn't rocket science.
I went to the ER with what was thought to be appendicitis and had a cortisol reading of less than 1.0 at 8am. Adrenal crisis, anyone? Fatal condition if not diagnosed, you know, rare metabolic disease or not.
When I was severly hypothyroid before my radiation (TSH over 150) I had chest pains and headache. I also felt very queasy.
Not saying that is her problem, just saying it can happen. I will give you that it is very unlikely though. I'll go back to lurking now.
Excellent points, thanks for your input.
Lumbar puncture required in the ER before admission to the ward.
Back when I was a resident (last millenium) we tried to give these patients who hadn't bathed in a while. Or one who got a lot of attention from a loving family - either one bothered them.
And there there is the "DC bed - pt must sleep on floor" order.
The more chief complaints you have, the less likely you have anything a hospital can fix.
Maybe not in Texas and probably doesn't explain everything, but Vitamin D deficiency. I saw an intriguing small study on Vitamin D deficiency and fibromyalgia--many with the second ended having the first. It would be interested to see more studies.
Admit. Always admit. Never wrong.
GruntDoc
Here's the thing...I have been diagnosed with fybromyalgia, chronic fatigue and rheumatoid arthritis. I also have tachycardia (which will be dealt with in April) and have had my gallbladder removed in December. Now I do suffer most of the things this patient suffers from but NEVER go to ER. Will I someday die of a illness I never knew I had simply because I attribute all symptoms to the above and ignore them? It's a dilemma isn't it...ciao
I'm a big fan of dope slap therapy. I'm also a NPC doc. Go figure.
So much like an xperience at KUMed Center in Kansas City. This looks lengthy, but you may find it interesting anyway.
30 yr old female, excruciating stomach/ abdominal pains,vomiting, can't hold water down, bouts of diarhea/ constipation, headaches, severe intermittent insomnia, extreme- to-suicidal depression, peripheral neuropathy, heart "feels like it's beating so heard it is outside my chest" (some abnormality), fatigue, body pain. Reported onset age 14- migraines,moderate asthma, severe endo, interstitial cystitis, frequent extreme urticaria causing emergency trtmnt for blood pressure crash. Reported 4 seizures in past couple yrs -tests negative;friends and family verified - ambulance called. Carcinoid tumor (6mm)found in appendix at age 14. (no follow up) Reported bouts of extreme depression in recent 2 years; hospitalized repeatedly(6-10 wk stays) took long list of psych meds. Full hysterectomy 2yrs prior, for incapacitating endo and 14yearly surgeries.Reported one terminated ectopic pregnancy 6yrs prior. Hysterectomy post op: L arm in terrible pain, like a vise, from BPcuff; hand dusky and cool to touch after 48hrs. Did brachial plexis and other nerve transmission work up: considerable damage. (after a year some feeling/use returned but patient in awful pain- was a professional guitarist and singer in a rock band - no longer able to play guitar- blamed for depression). During MRI for neck pain (degenerative disc disease with herniation),during same stay, found tumor in left orbital rim. Not followed up. Patient on morphine for most of 2 years.Placed on Methadone during this stay.Back to the current situation: gastro study = slow emptying only (blame morphine). Other tests normal range with fluctuating blood sugar (erratic ability to take in food or liquid), dehydration. Patient currently living with mother, can't work or handle own affairs. Has no insurance or money. No alcohol, drugs, smoking. Told she is a kook or drug addict repeatedly when going to ER. Treated extremely punitively by medical personnel. Mother asked about Addisons, AIP, carcinoid and was involved in care. She was considered kook too. Tests for AIP bungled 4 times, in normal range and inconclusive.To wind this up - patient still unable to eat much before surgery to remove orbital tumor. Tumor not identifiable but thought to be metastatic. Lab did not know what it was. (grew from 6mm to 12 in 2 yrs) Upon awakening from surgery, patient was ABLE to eat and drink normally. Stomach pain gone for most part after 48hrs. No longer so depressed. Family history of severe interstitial cystitis, asthma, hemachromatosis, IB type diseases (undiagnosed), degenerative dic disease @ early age with fusing surgeries, arthritis (not RA), female relatives develop moderate to severe Bi-polar episodes at age 28, ADD, no cancers before age 70, pre-cognition, severe migrains.
After 2 years, patient well adjusted, taking only meds for ADD and pain. She has learned that when she develops insomnia that depression and stomach pain will soon follow unless she sugar binges(candy 24hrs a day) which stops the progression. She treats the symptoms like AIP anyway. No, it wasn't Lyme or Lupus either,no lesions in GI tract- nodules- hypertension -heart lesions which would eliminate Churg-strauss, altho on the list of suspects. All possibilities have been eliminated. This Zebra is my daughter. We have a much reduced opinion of the medical profession after this experience. Shame for a patient to become an ANNOYING list of symptoms instead of a person. My diagnosis is still with AIP. Hard to prove but if I had the $$ I'd have her genetically tested. Also, I have always had the suspicion that the tumor in her Orbital socket was another carcinoid pumping out something that was contributing to the urticaria, although the lab would not specifically have an expert examine the tumor.
GruntDoc:
Just a friendly note from one of your hospitalist collegues.
If you admit "pain all over" with multiple negative workups (and nothing wrong with her), we;ll take it.
But the 2 hours we spend with her (and the 12 hours we spend with the other 6 pts just like her) are lost forever.
Also, she (and the cases like hers) will be a (non-reimbursed) bed for a week each.
In other words:
when you call me for the the pt in septic shock, or the one with the tumor eating half of his face, or the bleeder, I won't be able to get there for a while.
And when I do get there, I won't have a bed to put the dude in.
So that really sick pt who requires constant one to one nursing will be in your ER for 4 to 8 hours before being seen by the admitting doc and another 48 hours with orders waiting for bed.
Choice is up to you ER docs but we hospitalists (who are subsidized) will take whatever you give us.
Just not all at once.
Yup. Not to mention the damage to our credibility, which can't ever be regained.
As a psych resident, I'd respectfully ask that you do a thorough work-up before sending her my way (Though I'd probably order the MRI, TSH, B12, RBC-Folate anyway). Makes my job in convincing her that her "illness" has a psychiatric component, much easier. Thanks.
MS1 on 3/28: SLE can, rarely, cause esophageal stricture and achalasia, so progressive loss of solid & liquid tolerance often with chest pain and nocturnal exacerbation. For your notecard (because it's not common, but I've seen it once as a student, so you never know) :).
Otherwise, it seems to me that lots of people have made very good points about the differential diagnosis, but the overarching point is really the "no cookie" thing, isn't it? At what point is this patient no longer truly emergent? I'm not saying that the ER doc doesn't have the responsibility to try and figure out as much as possible, but at some point the possible diseases cease to be life-threatening, and the patient needs to see a doctor in a non-emergent setting for a more complete work-up.
So do you do the blood work-up knowing that very few of those possible causes is emergent? Do you do the CT/MRI knowing it will probably show the emergent things? Do you do the full work-up knowing that she may not see any other doctor and therefore none of the not-immediately-lethal causes will otherwise be missed?
I don't have an answer (because, really, I don't know much yet). And you're right, a lot of FP won't chase the zebras because they're often already overworked and one difficult patient can throw their entire clinic off (much like the ER, really). So how would this patient get her churg-strauss diagnosed if no one's really well-suited to diagnose it?
Naturally, if there is a psych diagnosis to be made, she's more than likely to end up failed by that sub-system as well, because there's no money and no practitioners. And once you get into the psych side of things, it's really hard to get back to non-psych causes.
You're absolutely right: no one gets a cookie. Or we all get one, and it's stale, made with rancid chocolate, and covered with bitter mold.
Does where you draw the line depend on the night in the ER? What do you actually do in cases like this? Did you diagnose her with fibromyalgia/anxiety/depression? Did you run the full work-up?
This case is sort of a mess, because (like most) it takes features from a multiple patients in an attempt to maintain a semblance of anonymity. There are a couple of key elements of the "main" patient's medical history that I can't divulge because they are way too specific, which is frustrating because it would make the discussion much more interesting and relevant.
I didn't perform any exotic tests, but then again I don't like to order tests that won't change my ultimate disposition. These comments have given me some ideas to consider if I see her (or someone like her) again. And for that, I am grateful to each of you.
We don't really have to make a specific diagnosis in the ER; all we have to do is to accurately determine whether an emergent condition exists. "Viral syndrome" or "Chest Pain - unspecified" are as good as any.
That's what makes the next case I will post so unusual...it's a rare and exciting diagnosis actually made by an ER doc in the trenches. Unfortunately, I can't take credit for it; a buddy of mine e-mailed the story to me. Stay tuned, it's a great case!
I'm not a doctor, I'm mentally ill and I know of science and trust its reality.
She has normal oxygen, can walk, physical diagnositic tests have been done in the past that reviel nothing wrong.
Call in an Exorcist to cast out her demons, or have her husband commit her to the mental hospital for being a bad wife.
Scroll down to find the text
"Husbands ridding themselves of wives via the psychiatric institution was still enough of a problem in the 1930s that the first woman in Maine's legislature, Gail Laughlin, authorized a bill penalizing husbands for bringing false testimony in the involuntary commitment hearings of their wives. I worked with a patient who in the 1960s had been brought to the hospital by her husband. The chief complaint listed on the admitting record was:
"Patient does not do her housework."
If you guys had a few of these malingering, pain-all-over types who are mentally ill I could totally buy that some people just need attention. The problem is that you have TONS of them.
Are there really that many lonely people in the world-or do you guys not have a good handle on what's wrong with these folks???
I come from a family with a genetic hypochondriacism. My GGrand mom, Grandmom, mom, sister, myself all have chronic joint-muscle pain, stomach inflammation, biliary dyskenesia, duodenal pain, this really cool eye problem called visual snow, silent hypothyroidism w TSH>200, and fatigue.
When diagnosed with hypo I lost 20 lbs in two weeks, became so dehydrated my skin stood up in folds, started having delusions when I drank water with profound salt cravings. At one point my speech was horrifically slurred and I couldnt control my hands anymore to write with. They told me it was an anxiety problem. Since I didn't have addisons I was sent home as a psych case.
On another round of illness my BP would drop from 120/90 am to 65/40 pm and I couldn't stand up after 3 pm. My husband left me during this spell. loser.
Maybe you need a new class of dr to address these folks. Somebody who will seriously spend some time understanding the neuro-hormonal problems that seem to underlie these problems. Think about all the test/exam revenue you guys could generate doing level 5 exams on us maligerers. See the financial incentive??
Tina
Oh WTF, not like you guys will listen anyways.
-try giving patient like this florinef and having them drink more water to increase BP.
-If that doesn't work try giving them ADH like you do little kids who wet the bed. This might work as long as they keep salt intake up to prevent hyponutremia.
-problems like this may arise out of decreased cortisol secretion via the brain downregulating cortisol production-It's a theory. Depression is thought to arise from excess cortisol. So giving sombody like this antidepressents may only make the problem worse. ADH has very recently be found to coregulate ACTH secretion in conjunction with CRH (see vasopressin).
stuff to search pubmed for:
vasopressin/ADH
cortisol regulation
cerebral salt wasting syndrome
hypermobility syndromes
my guess is better than you guys' lack of a guess.
If we do basic blood tests with cardiac enzymes and add an EKG and a chest X-ray, that's a level 5 bill already. ER docs don't make more money if we order more tests beyond those. Throw in a CT scan or two or a repeat blood draw for an exotic test, and we actually make less money due to the room being unavailable for other patients.
There are indeed plenty of lonely people who lie to us every day and who really want to be sick (and to be admitted to the hospital) but aren't. That's what makes rooting out the truly sick ones so difficult sometimes.
If you are actually hypotensive and dehydrated with abnormal electrolytes and an abnormal TSH, then you wouldn't be lumped in with those other folks. But we have to order dozens of TSHs to find one significantly abnormal one amongst the somatoformers.
I'm skeptical about the value of a random cortisol level in the diagnosis of adrenal insufficiency in the ER setting, but if you have any links to such studies I'd be interested to see them.
Timing is everything when it comes to cortisol, diurnal rhythm and all.
Normal for 8am? 8-23 Normal for midnight? Zero
Should you hold onto that patient until 8am? Ha ha ha; uh probably no. But my favorite dude in the internet medical world, no offense to anyone, is Ed. Have you seen his site? www.pathguy.com
The whole business is very complicated. If your screening tests support your idea that the patient has any endocrine disease, it is usually best to obtain consultation with an endocrinologist.
ADRENAL CORTICAL DISEASES
Cushing's syndrome: increased cortisol
increased glucose, decreased K, decreased lymphs, decreased eos may be noted
Cushing's disease (pituitary adenoma or microadenoma): increased ACTH
Adrenal cortical adenoma or carcinoma: decreased ACTH (maybe....)
Ectopic ACTH production (i.e., oat cell carcinoma, carcinoid, thymoma, pheochromocytoma) or CRF production (oat cell, rarely others)
Iatrogenic (glucocorticoid therapy)
Addison's disease: decreased cortisol (or decreased ability to produce cortisol)
decreased glucose, increased K, increased BUN (prerenal azotemia) may be noted
Primary addisonism (autoimmune, TB, after steroid Rx, etc.): increased ACTH
Secondary addisonism (hypopituitarism): decreased ACTH (maybe....)"
also by pathguy:
If your patient's "spot" cortisol at 6-8 AM is less than 80 nonamoles/L, it's either addisonism or binding protein deficiency. However, a "spot" plasma cortisol may be normal in all but the worst cases of adrenal insufficiency (addisonism). Therefore, it should not be used alone as a screening test for adrenal insufficiency!
A patient with marginal adrenal cortical function is likely to have a normal plasma cortisol but suffer "Addisonian crisis" under stress (illness, surgery, endocrine testing....) Such a person may even pass the ACTH stimulation test, and some surgeons give post-surgical patients with high-output, low-peripheral-resistance shock a bolus of glucocorticoids (Arch. Surg. 128: 673, 1993).
I'll be honest, most endocrinologists don't have a firm grip on negative feedback systems. They are like the accountants of the medical world, numbers matter only the numbers matter; trust me on that one. So why worry yourself about these fleeting & rare diagnoses in the ER? Not only do patients not know about the possibility of the disease, neither do their doctors - they don't think of it. :(
But the most persuading reason I can think of for doing a check-see is the stunning ability for an Addison's patient to drop dead suddenly - "in the 1950s, before the availability of glucocorticoids, the 1-yr survival rate in patients with Addison’s disease was 20% or less (12)" could easily read "unless diagnosed, the 1-yr survival rate in patients with Addison's disease is 20% or less". Yikes.
http://jcem.endojournals.org/cgi/content/full/91/12/4849
Eh, you can't win them all Scalpy. :)
In my belief system, the rare and exotic diagnosis, even if incorrect, gets more credit than the mundane but accurate one. For that reason I choose to consider these patients prodromal for an exotic diagnosis, such as porphyria cutanea tarda, rather than fibro.
"But the most persuading reason I can think of for doing a check-see is the stunning ability for an Addison's patient to drop dead suddenly."
So you contend that despite the fact that there is no reasonable ER test for this condition, we should still do an essentially worthless test for a condition that has an incidence of about 1/200,000 in case we are unfortunate enough to draw the even rarer Addison's patient who, despite having normal baseline labs, might just drop dead suddenly regardless.
If I worried that much about people dropping dead from rare conditions, I'd never be able to discharge anyone ever. You need three things to be a successful ER doc: medical judgment and balls.
Heh.
anxiety.
So you contend that despite the fact that there is no reasonable ER test for this condition, we should still do an essentially worthless test for a condition that has an incidence of about 1/200,000 in case we are unfortunate enough to draw the even rarer Addison's patient who, despite having normal baseline labs, might just drop dead suddenly regardless.
I don't know if the test is worthless in an ER setting. It may be worthless as a diagnostic test, when an ACTH Stim test is better suited. I highly doubt that the people about to drop like a fly, go home to belly up, kick the bucket, buy the farm, etc are going to wow you with a normal reading. You know what I mean?
I only posted, not just due to my undying love for youuuu Scalpy - but the incidence of psych consults (real or imagined) without checking for blatent markers of endocrine disease.
"Four case series published in the 1940s and 1950s found the prevalence of psychiatric symptoms in Addison’s disease to be between 64% and 84%.3–6 <-- In the 40's and 50's, people! Gaah!
http://neuro.psychiatryonline.org/cgi/content/full/18/4/450
Back to that chest pain complaint I mentioned:
"RESULT: A 48 years old male presented in our medical outpatient department with a three day history of sudden onset of severe precordial chest pain that started while playing football which was associated with nausea, vomiting and difficulty in breathing. After initial clinical evaluation a diagnosis of acute myocardial infarction and cardiac failure with a suspicion of background Addison's disease was made. Serial electrocardiography done over a two week period did not show evidence of myocardial infarction, but the patient had elevated serum ACTH and very low serum cortisol levels."
http://www.ncbi.nlm.nih.gov/pubmed/17111738?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA
I don't care if you send everyone with a twitch to consult with a psychologist, I live in California. ;)
I've seen House...
It's never Lupus.
hi scalpel,
I dont think a random cortisol would be of much use, as that test has to be shipped out to a ref lab with a turn around time of a few days-at least where i live. I think its done by hplc or gc, thus not a good STAT test. Id suggest ordering it, suggesting they visit thier GP anf having the GP pull the results. Worst case, they are normal. If they are about to drop, Id expect youd notice.
As for the comments earlier about cortisol levels, that isnt in reference to addisons. it was about the malingerers. The thought is that lowered cortisol levels give rise to CFS and fibro. Not low enough to cause true AI but low enough to make folks miserable. High cortisol gives rise to true depression-the type that makes people not get out of bed.
Endocrinologists are great at the all or non approach, however it took nueroscientists to tease apart more subtle abnormalities. And yes it may be all in their heads-their hypothalamus/cortex to be exact.
Apathy and Pituitary Disease: It Has Nothing to Do With Depression
Hi Lisa,
That's an interesting paper. I have also heard about methylphenidate used in CFS with good results.
When in grad school at Umich I was diagnosed with ADHD and put on ritalin. It helped so much at first but then the washout was so bad that I would get really ill. That's what happens when you treat profound hypothyroidism with ritalin I guess! The fun of an HMO...
I vote for testing the patient for hypothyroidism since she's middle aged.
Chest pain, nausea, vomiting, in a bathrobe by 2pm sounds just about right for thyroid disease. She probably depressed and who wouldn't be feeling that way day after day and with no one understanding how ill she feels.
And make sure you do a full panel: TSH, FT4/FT3, thyroid antibodies, and a chest x-ray. Pleural effusion is a symptom of hypothyroidism and that causes chest pain.
Yes, a patient like this looks like a kook and that they're possibly faking it. But that's usually how thyroid disease presents. You look like a hypochondriac, but in reality you're suffering.
It takes four actions to make an accurate diagnosis: a good and thorough history, observation/notation of clinical signs, appropriate lab tests, x-rays, MRI's, etc., and knowing how to listen to the patient's symptoms and complaints.
I know that this an an ancient discussion that probably nobody is reading anymore, but I just have to say something . . . As someone who does psych consults, I certainly think that an evaluation on this woman is warranted. But here's the thing: you guys want me to come in and do an evaluation that will prove that her problems are psychogenic. And that is the most benign spin. What most of you would really like is to see me prove your hypothesis that she's actually a whiny, hysterical kook. As someone who isn't a REAL doctor (I only have a Ph.D.)this often places me in an extremely difficult position because even if I'm pretty sure that the problems are purely psychogenic, I'm being sent in kind of under false pretenses. The patient thinks I'm there to help, when actually I'm supposed to be a character assassin. Nice. But I really appreciated the people who noted that patients who have been sick for a long time usually end up looking and feeling pretty depressed; that made me feel like there might be some hope . . .
I should offer the disclaimer that a case like this would not really come my way . . . I work in a prison. On the other hand, I've seen some Zebras that were missed in other facilities - it's hard to know why, of course, but there's a dangerous myth that inmates NEVER tell the truth about anything. When this is combined with the fact that all of us sometimes have a hard time remembering that hypochondriacs can get sick too, then bad things sometimes happen.
So here's the point of my little rant: if you ask for a psych consult, please use the data. Even if it doesn't say what you wanted it to say. I mean, if you get a lab result, and that wrecks your hypothesis, you'd go back to the drawing board, right? So don't treat the psychologist or psychiatrist any differently. Please? It's incredibly hard to tease out a mood disorder when someone's life legitimately sucks, and people who have chronic pain or have chronic illnesses often have neurovegetative symptoms that can make it difficult too. Sleep deprivation also has effects that look astonishingly close to depression too, and it's hard to get at those differences because people feel so crummy that that they have a hard time telling you that they really aren't depressed. Some things I would ask this woman or her husband? How long have you been like this? Has this ever happened before? And who else in your family gets like this? Maybe phrase this as a question about mood, maybe not. Probably not, though, because those questions tend to answer themselves in the end. I can't remember how old she is, but that is an important clue to diagnosis. Serious mood disturbance tends to be chronic. Chronic mood disorders tend to have onset in adolescence or young adulthood. At the very least you can see the roots of them then. Also, mood disorders do remit. If she's been like this for longer than six months, especially if the decline is precipitous that is cause for concern. Self-esteem and self-concept are important areas to assess (in my mind a pathognomic sign, but maybe not everyone would agree). If you decide to forego the psych consult, please keep in mind that depression is a mood disorder that may have accompanying somatic symptoms. It is not a somatic disorder with some mood stuff thrown in. Are we sure that she actually meets criteria for a mood disorder? I'm afraid this means asking her about her mood symptoms and checking them against the DSM-IV-TR. maybe she meets criteria, maybe not. And of course, she could be depressed AND sick as several of you pointed out. Interesting case, but I have to admit I have no idea what's wrong. Autoimmune DO jumped into my head, but my ocasional flair for olfactory diagnosis isn't much help here. It is interesting and perhaps significant that her husband is on her side, though.
Cindy M.
P.S. Okay. In the interests of full disclosure I will sum up my own personal story with this: I've had a bunch of vague symptoms over the past year or so, though it goes back farther if my hindsight is 20/20. If I'm a headcase, then I've been a headcase for more than a year or so. I was promptly diagnosed with "stress" and referred to a therapist. In the meantime a bunch of blood was drawn. I went to see a therapist, which was probably a good thing for me, but I was pronounced "not a professional menace." But this was my silly expression - not the therapist's! In other words, I didn't HAVE to go! In the meantime the blood came back, mostly normal, but with a couple of oddities. Then I got worse. Then better. Then worse, then somewhat better, then a little worse, then a little better, but no symptoms that anyone really wants to deal with and by that time I couldn't produce an abnormal lab result to save my life. Eventually I developed a hypothesis about what was wrong, but nobody liked it because they thought that my theory was unlikely (which I have never denied). But they are arguing from the perspective of base rates, whereas I am saying that they maybe shouldn't: given my symptoms, maybe they should take my hypothesis a little more seriously. But all the M.D.'s (except the psychiatrist) are convinced that it's either "stress" or a mood disorder even though the mental health people have said this doesn't seem like a very good explanation for my symptoms. But unfortunately, I'm one of those mental health people, so the last consultant that said my symptoms were related to stress and mood. He also said that I lacked insight. I cannot convey how crushing it was to read that - especially since it was followed by a thanks to my PCP for the opportunity to evaluate this "very challenging patient." A triple slap in the face since I was self-referred, since the whole "stress" thing was the reason for the referral and I'd never tried to hide that, and worst of all he must surely have known that that I would understand what that "code" meant. So I'll admit that I might have a little bit of a chip on my shoulder even though I really try not to. I don't know if there's anything medically wrong or not, but now it doesn't even matter. I'm a head case. Fortunately, even if I'm right it's not something that will kill me this week. But there's no way on earth I'm going to make myself look crazier by bringing this up again. I don't know what kind of lifestyle I would need to have in order to be immune from from the diagnosis of too much stress, but I doubt I will ever have it. I may lack insight, but I don't think I'm stupid and I'm not one to give my head for washing!
The answer is always more Dilaudid. Hell, you can cure anything with Dilaudid... pain (the only approved use, but not the ONLY use!), depression, anxiety, coughing.
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