Mariya (0nce) wrote,
Mariya
0nce

Under the cut, an incoherent log of my 7 ER hours, not well-written, sort of self-indulgent... Want to keep a record of people and cases, without knowing exactly why. Wow, latenight splitting headache, maybe I have encephalitis; Imma get me a spinal tap the next time I come in. Here goes.



Summary: If yesterday was the chemotherapy-associated sepsis day, today screamed "ATYPICAL CHEST PAIN," in bright capital letters, written across something expansive and hemispherical that draws perverse attention and preferably includes a navel, as a focal point.
At least 6 atypical chest pains; two were pregnant women [which complicates things; will elaborate]. Dr. N and I actually had our first-ever flash-bonding-high-five-worthy-moment-of-brilliance {FBHFWMOB}, when, after seeing one of the last patients of the day [a male], he read out loud the notes that he was writing ["atypical chest pain"] and we had the same thought simultaneously [he: "At least we know he's not...; I: Let's check if he's.... (pregnant)].


Miscellaneous notes to self, medical, unattached to patients:
 
X-ray: useful to rule out pneumonia [esp. with high WBC count] and pneumothorax [esp. in young people]. Fluid from pulmonary edema/congestive heart failure could also be detected, but it would be pretty obvious from communicating with the patient if this is going on.
Pushing on sternum: if pain, probably arthritic and not cardiac.

Question to self: Why is D-Dimer elevated in pregnantfolk?

TIA = transient ischemic attack

When PubMed "unexplained chest pain" or "atypical chest pain", results in myriad articles about the PSYCHOMAMMOTH-SIZED correlation with SPECIFIC mental health disorders [most frequently, panic disorder -- 47%! depressive disorders in 21%]. Other explanations include acid reflux, motor disorder, altered pain threshold... Plus peptic ulcer, esophagitis [treated by adding an "o" to the beginning of the word] , pancreatitis, gallstone. Treat with proton pump inhibitors for a week, see what transpires; if improvement, continue 4-8 weeks. Also, proton-pump inhibitors = commonly-used antacids = wtf, who knew?


Miscellaneous notes to self, personal:

Dr. N threatens hospital employees not to let him near a microphone, after gospel-serenading a clerk. Probably still thinks he should have been an actor.
Dr. N keeps track of his prejudices, and makes explicit that this is important to him. We had an obese patient today, and I could see him struggling.


Patients:

Patient 1: Man, 41 yrs old. Chest pain started during physical exertion. Mentioned - under stress [family problems].
Note to self: there needs to be a better way to offer psychological services to a patient in the ER; "Do you need to talk to somebody about that?" is something that I can imagine few people answering affirmatively.
HIstory of hypertension, mom has heart disease. Pain in 1 spot. Pushed on sternum => no added pain. Poor man now in the hall, waiting for X-ray. Notes stop here.

Patient 2: This poor woman was napping on a stretcher in the hall [her labeled room is "Ice machine" because there are more patients than rooms] my entire shift. Black female with sickle-cell. Reported chest pain. Probably a diffuse sickle-cell crisis. Acute chest syndrome possible if cells get stuck near lungs. Ouch. Dr. N. says that in his experience, sickle-cell patients are often dependent on pain meds. I believe we ended up doing nothing more than giving her pain meds because nothing else was found.

Patient 3: Pregnant woman, 2nd child, 1st 4 years old. Chest pain radiates to left shoulder. Short of breath, but probably cuz 6 months pregnant.
Dilemma: would do X-ray or CT [CT preferable for diagnosis, but more radiation] to rule out pneumonia/stuff, but usually not done on pregnant women due to risk to fetus. Usually, risk extremely low >12 weeks, but still want to be on t he safe side [esp. for the parents' sake]. However, when D-dimer comes up positive [usually the case in pregnant women anyway; only a negative test would rule out Pulm.Emb.], bloodwork is inconclusive, and EKG is fine, nothing else to do. To send home with severe chest pain [risk of pulmonary embolism], or to take the minor risk to fetus?
Took doppler of legs [if blood clot detected in legs, would need to give blood thinner anyway, which would rule out necessity of looking for clot near lungs], negative. Coumadin is risky for pregnant women anyway.
This patient, indeed, had an elevated dimer.

Patient 4: Lady, 38 years old. Reports severe chest pain; can't sit at work or be functional, so bad she's crying. WBC elevated. Pain radiates to L arm; sharp, btwn shoulder blades; hurts to talk, breathe deeply. D-dimer normal, X-ray looks normal [she had lung malignancy before; could see results of that surgery, but nothing new]. She became really angry/agitated at one point, demanding diagnosis, doing the equivalent of slamming doors, which in the ER amounts to pulling curtains. Dr. N concluded that he'd send her for a CT scan just ot be sure; this came back later, negative. Couldn't find anything with her; nothing dangerous seemed to be going on. Sent her home with pain meds -- Vicoprofen [Vicodin and Ibuprofen; can't decide whether it's lame or totally rad to keep them together like this and fix their relative doses].

Patient 5: Older male, has tracheotomy tube. Probably still on chemo. Had chills and very high fever. With him, we were afraid of pneumonia, so automatically put him on IV antibiotics. At 2PM , temp. 98.9 [though he told me that he got tylenol at 11 AM, so I'm not sure how much that means]. Probably bronchitis. His bp was low -- 100/65, though he's been running low lately. Risk of sepsis. Dr. N wanted to send him home, I questioned this more vocally than I intended to, he started becoming doubtful, went back to the patient, talked more to  him and his wife, decided that since he looked OK to his wife, they could go home and just watch him closely. Bye, awesome man.

ZOMG feel like bones are breaking so exhausted must sleep; 5 more patients to be bloggified soon, hopefully. Good night.
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This is fascinating. Please post more of these all the time.
Funny, my boss just spent much of our meeting this morning/afternoon on Non-Profit Management 101 counseling against navel-gazing.
I hear him completely. Navels are terrifying.
I love!
Was thinking about doing similar, but less detailed. (On a sidenote, omgz I am so excited about the fact that I get to see OB patients now, and not just GYN ones! Hooray!)
I second Sara -- please post more!