Let pain be your guide
Sunday, November 30, 2008
Anil
In room 7 waited a 54 yo man with a history of kidney stones and a complaint of pain in his lower back. I've never had a kidney stone and from what I have seen I am happy not to experience that pain. This man held his lower back with his left hand and grimaced in pain, so I quickly put in orders for medication and told the radiologist to keep him in the cue for a CT scan. We usually do not give contrast when we look for a kidney stone, which means that there is no dye running through his vessels, and the stone often appears as a bright rock in the ureter.
After about an hour, when the scan was completed, that bright rock never appeared in any of the images. And, despite receiving a heafty dose of Dilaudid, he still complained of a severe pain and clutched his lower back which was very tender to touch. A healthy, middle aged man, with normal lab tests, and a normal non-contrast CT scan is usually pretty safe. Nonetheless, his level of pain seemed to indicate something different.
Though my experience indicated that this patient was probably just fine, my intuition and his pain drove me to keep searching. I checked his abdomen with an ultrasound, looking at his gall bladder which seemed normal, and I moved closer to his left, where his pain was, to look at his aorta which also appeared to be normal. A constrast CT would inject dye thorugh his vessels and allows the scan to show more subtle findings such as a tear in the aorta. We agreed to do this study and discovered that he did, indeed, have such a tear.
As I reflect on his case, I feel relieved that he is now doing well in the hospital and I am glad that we kept digging. Sometimes pain is hard to control, but it is always our best guide to finding disease in any individual.
4 Comments:
At Fri Dec 19, 05:10:00 PM 2008,
Anonymous said…
I went to the ER in Oklahoma with severe pain in my upper right abdomen. They first had a PA run an xray of my colon and I was told it was just gas although I told him, and I am a 56 year old female, that I never had gas pain like that. He laughed and sent me home.
The next morning my husband called an ambulance I was in so much pain I couldn't move. It was in the upper right abdomen under the rib cage. It hurt to breath. Suddenly as the EMT's were working on me I felt a rush of hot liquid across my upper abdomen which then spread to my mid abdomen and then lower abdomen. The muscles in my thighs started to spasm. The pain in my upper right abdomen now decreased and I felt pressure from the hot liquid in my lower groin area.
When I arrived back at the same ER they ordered me to drink something and then did a cat scan. They said my problem was beyond the scope of their ER department.
I have since been to a gastroenterologist who still seem to have a problem grasping the severity of the problem . My right side is starting to hurt again and I don't know if I can survive another rupture. Where do I go? What do I do? How do I find someone who will treat this thing and not jus wait for me to die.
Miserable in oklahoma
At Sun Jan 25, 08:59:00 AM 2009,
FeatherMe said…
I wish I had someone like you around where I live. I was just in the hospital - came out of surgery moaning and groaning with screams of chest pain like I've never had before - troponin level 0.54 and had a heart cath. The cardiologist said my heart was perfectly fine and I should just ignore the pain. That's probably why more women die or don't seek help soon enough for heart attacks.
It seems from another cardiologist's point of view that all EKGs are invalid because of poor lead placement. Why do them?
The 64 cut scan said I had coronary artery stenosis in two of the arteries, my ekgs are always abnormal and progressively so, I take toprol xl for SVT and PACs,Carotids, internal, have stenoses, LVH, Left axis deviation, echos show mild regurgitation in a couple of valves, and there is aortic calcification. Also MI age undetermined. What a waste of my time and money! All for proving nothing is right or wrong!
I have come to the opinion that there will be no more surgery - can't handle anesthesia well - and definitely no more testing if I do bother to go see any doctors again.
Your patients are very fortunate. Keep up the good work.
At Sat Feb 07, 12:38:00 PM 2009,
Bianca Castafiore said…
I cannot help but wonder whether the same presentation, in a woman rather than a man, would have led to continued exploration for a cause on your part, or might you have decided she was drug or attention seeking?
I know what is going to happen... you will have HIPAA-ized the patient precisely by a gender change!
Good job on this case!
At Sat Jun 20, 02:22:00 PM 2009,
Disability Insurance said…
Great article, I guess pain can be misleading at times. Being a resident it shows that you are definitely always learning.
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