“You took erythromycin for…what now?!”

19 year old female being triaged. The triage nurse asks: “What brings you to ED today?”
“I have taken some medication.”
“Yes? What have you taken?”
“About 6 or 7 paracetamol, and 5 erythromycin.”
“OK. What time did you take these medicines?”
“Umm…like around 4 o clock (about 6-7 hours back)”
“Right. And what was your intention?”
“Well, I had a very bad headache.”
“I really wanted to get rid of this terrible headache.”
“…”   *stares*
“Yeah I know. I didn’t know what else to do, so I just took whatever was available.”
“You…took these medications by accident then?”
“So you took paracetamol and…erythromycin (!!!) for a headache?”
“You had no intention of harming yourself in any way?”
“No of course not! I told you, I wanted to cure my headache. Why would I want to harm myself?”
“Are you aware that erythromycin is an antibiotic and doesn’t really have any effect on headaches?”
“Yes. But my headache is gone now.” *smirks*

The chest pain that just…kept on giving!

I had the pleasure of seeing this patient, elderly around 75-80 year old male, and you know how you sometimes really connect with someone? Hit it right off even if you are in a hospital cubicle and they’re in pain and you’re the doctor and the nurse is connecting the ECG electrodes to their chest and you are holding their hand? No? Never happened to you guys? Hmmm.

Well, as I said, I had the pleasure of picking up this patient’s card. He had come in with chest pain, that had begun that evening, and he was concerned enough to call an ambulance. His past history was significant for hypertension (high blood pressure) for which he was on x 2 medications, and angina (chest pain, cardiac in origin, usually when you exert yourself, and relieved by rest and/or some medication under the tongue, does not signify lasting cardiac damage, but does signify some degree of cardiac disease). He also had a family history of cardiac disease.

He was otherwise very fit and well, jogged and took his dogs for walks etc daily. Non smoker. He hadn’t had an episode of angina in the last few years, but for the past 2-3 weeks he was having recurrent chest pains, that initially seemed like his usual angina (started on exertion, relieved by rest) but then progressively began to occur with less and less exercise and now for the past 2 days he had had episodes of chest pain at rest, and this latest episode he was lying in bed, reading! On arrival to ED his observations were all within normal limits, and his ECG was within normal limits – slight changes but when compared to a previous one we had on record it was essentially the same. There were no significant findings one examination and his blood tests and CXR were within normal limits. Even so, he was having chest pains with gradually decreasing amounts of exertion, and also at rest (his angina had progressed to a variant known as unstable angina) – he was going to have to stay in hospital for observation, further investigation and a cardiology opinion about whether or not he needed to have an angiogram done. When I broke the news to him, the rather stoic-appearing gentleman became teary-eyed and red-faced; he was quite upset at the thought of having to stay in hospital. I assured him there was nothing horribly horrendous going on, but we were trying to do whatever was the safest course of action for him. He understood of course, but he was still quite reluctant to stay. His wife finally convinced him to stay, and I referred him on to the cardiology unit. And that was that. Or so I thought.

3 weeks later, I picked up a card for the next patient who had come in with chest pain. The name didn’t ring a bell – you see so many patients on a daily basis, it would be impossible for every patient’s nomenclature to remain in your mind’s database. As I stepped in to the cubicle and pulled the curtains behind me, I opened my mouth to introduce myself but the patient beat me to it by exclaiming that he had seen me before – that he was one of my regulars now. I still didn’t recognize him but he then proceeded to outline what had happened on his last attendance, and it became clear: this was the same patient. I asked him what had brought him to ED this time. He reported he had been out of hospital only a week. “Wait a minute, hang on, you say you were discharged just a week ago? But I admitted you ages ago, have you been in hospital all this time?” I was incredulous. He smiled and told me he had had an angiogram during his previous admission, and found to have ‘a lot of clogged arteries’ so he was referred to nearby cardiothoracic surgery hospital for a Coronary Artery Bypass Graft – or CABG, better known as a heart bypass – 2 weeks back! I was shocked, and at a loss for words, and didn’t really know how to proceed with the conversation. Here was a guy who had come in with chest pain not 3 weeks ago, and I had admitted him for observation and further investigation, yet he had somehow had a bypass done in the interim, and also now ironically come back with some more chest pain – anginal symptoms to be exact! Which is unusual, because a CABG would treat the exact anginal symptoms he used to have, and for him to have the misfortune of having cardiac-sounding chest pain, that begins at exertion and relieves at rest (the reason he presented this time) and for him to actually end up in hospital with it; coupled with the misfortune of seeing me as his doctor, again, when I had been the harbinger of bad news previously – it really couldn’t get any worse now, could it? I went about asking him for a detailed history of the events causing him to attend this time, and examined him fully. His ECG showed some changes, but I was unsure if this was now normal for him, since he had recently had cardiac surgery (not two weeks ago!!!). He was currently pain-free, and at no point during the chest pain episode this time did he have any shortness of breath, and no coughs or fevers. Pain was reproducible on palpation of sternum (following chest recently being cracked open, that wasn’t really an unusual finding). He did not have any difficulty taking in deep breaths and the pain did not recur or increase with taking deep breaths – it was non pleuritic and so I basically ruled out a clot on the lungs in his case base on symptoms. He wasn’t even tachycardiac. The holy trinity of a pulmonary embolism or a clot on the lungs is surgery or immobilization for the past few days, chest pain associated with shortness of breath and tachycardia, with an increase in pain on taking a deep breath. He did report some pain and swelling of his left lower leg but that was normal in someone who had only a few days previously had had surgery to remove one of the long veins of his legs to use as a bypassing vessel in his heart – the wound itself was healing and dry, and did not look infected; he reported the swelling was improving since his surgery. I did a baseline set of bloods, including a troponin (enzyme that leaks into blood upon cardiac muscle damage) which came back slightly raised at 28 (normal range is below 14) and it was probably still coming down from his recent cardiac events. I added d-dimers to his bloods – and they came back as positive at 2700 (normal range is less than 230) but they can be raised in many conditions, including pulmonary embolism but also major surgery, pregnancy and infection. The D-dimers seemed to be in keeping with someone who had recently had major surgery, but I still spoke to the medical registrar – I was not going to administer anticoagulants to someone who had just had cardiothoracic surgery! They requested a CT scan of the pulmonary vasculature with contrast, and diagnosed pulmonary embolism.

To this day he remains my only patient who really tested all my differentials of chest pain during our multitude of interactions – I considered him to have at least 4 causes of chest pain at different points in time: Angina (prior history); Unstable angina/ACS (first visit to hospital); Musculoskeletal chest pain (tender anterior chest due to surgical wound); and pulmonary embolism. Wow.

An interesting lump, courtesy of Warfarin – a dilemma in clinical management

59 Year old female came in to ED due to a painful lump that she had noticed overnight in the right side of her abdomen, associated with pain in the right half of her abdomen, back and upper part of her hip. This was the vague and slightly confusing history on the card as I went to review her. She was a very pleasant lady, who walked into the cubicle without assistance, no support required – and clearly no hip pain?

She reported she had had a cough x 6 weeks – not continuous, but had had a chest infection initially, and was still recovering from that about 3 weeks back when she began to have productive cough and fevers again – and had to complete a second lot of antibiotics, the last of which finished yesterday. She still had bouts of cough though, even though it had improved considerably – one of which had happened last night just as she was going to bed. She couldn’t sleep all night due to the continuous coughing, but this wasn’t the reason why she was here that morning. She woke up in the morning feeling quite sore in her upper abdomen, and put that down to her constant coughing. She tried to ignore it, and took some paracetamol, but as she tried to dress herself, she felt that she required help with undressing and dressing, which was a concern. To top it off, she also noticed in the shower that morning that she had a palpable tender lump under her ribs, in the upper part of her abdomen on the right side. This concerned her enough to come to the hospital. Oh, and she was on warfarin – that lovely blood thinning medication that’s given for clots in the lungs or in the legs, or if you have a heart rhythm disturbance that makes you prone to throw clots to your brain – for recurrent PEs (clots on the lung) and her last INR was 2.6 (a test to see if the warfarin is doing what it is supposed to be doing, and whether it was doing more or less than it was supposed to be doing – recommended range for her condition was between 2.5-3.5)

When I examined her there appeared to be no bruising to the area in question, and her abdomen was soft, though there was definitely a palpable tender firm swelling in the right upper quadrant, sort of jutting out of the lateral aspect of her liver – my thoughts immediately went to a spontaneous hepatoma/bleed into her liver because of her being on the warfarin – I quickly ticked off in my mind a checklist of things that would signify severe ongoing bleeding internally, like pulse and blood pressure (both within normal ranges for her) and she appeared nice and ‘hemoglobin-y’ – adequately perfused! I decided to request a quick ECG (which was normal sinus rhythm) and did some baseline bloods on her including a clotting screen (to check her haemoglobin and INR today – both were normal, though a slightly raised white cell count and CRP) as well as a chest x-ray (I felt there were two reasons for this: 1) cough for 6 weeks gradually worsening, warranted radiographic evidence and 2) in someone presenting with tenderness of right upper quadrant, it is very relevant to be thinking about problems with the lower part of the lung above, rather than just focussing on the abdominal complaint – she may well have a pneumonia sitting in her right lung base, causing pain in her right upper quadrant! In this case, however there was nothing nasty on the chest x-ray on the right, though you could argue the left lung base looked slightly more hazy than I would have liked; at any rate, she needed treatment for an LRTI)

I spoke to my consultant, who quickly magicked an ultrasound machine within the ED and did what is called a ‘FAST’ scan, an ultrasound to quickly rule out free fluid within the abdominal cavity, usually done for patients of abdominal trauma to look for bleeding, etc. The scan was negative for free fluid within the abdominal cavity (we both breathed sighs of relief!), however we did find what seemed to be a collection of blood within the abdominal wall in the area of pain – she seemed to have bled into her abdominal wall, probably due to the coughing, which caused a tear within the muscle wall, and due to her being on the warfarin, caused her to bleed internally but contained within the wall of the abdomen – causing her presentation of a tender painful lump in her abdomen. Mystery solved. Now to the management of said mystery.

The dilemma we faced was this: We couldn’t stop her Warfarin due to the indication for which she was taking it in the first place – it could prove fatal if she had a clot on the lungs again. We couldn’t just leave her bleeding on the warfarin and do nothing. We needed to treat her cough as well, because even if it wasn’t life-threatening at this point, if she went on coughing, who knew how much worse this bleeding might get? And we had limited treatment options for her cough-slash-chest-infection, because many drugs including some antibiotics interfere with the action of warfarin, and the patient was allergic to penicillin (of course, we wouldn’t want this to be too easy!)

So we requested a formal ultrasound from the radiology department – much more detailed than our very ‘FAST’ scan. They agreed with our preliminary findings, with the very valuable additional information that there seemed to be no evidence of ongoing bleeding – the hematoma was contained and was not likely to worsen. Her INR was within the limits appropriate for her, maybe slightly on the higher side, so we decided to advise her to skip the next dose of her warfarin, and to liaise with the anticoagulant monitoring service to monitor her INR in the next few days to make sure it was still within the prescribed limits for her. We sent a sample of her sputum for culture and sensitivity, and based on the haziness in the left lung base and the raised inflammatory markers (CRP and white cells) we decided to start her on some antibiotics – she was allergic to penicillin, and so the next best option was clarithromycin which unfortunately interacted with warfarin so we couldn’t go down that route; we decided on doxycycline being the best line of treatment for her. We explained to her any of the red flag signs, if she experienced any concerning symptoms, to come straight back for review. We advised some analgesia, and some cough medication as well, and the patient was very happy to go home. Fingers crossed, she has neither returned nor have I heard of any problems coming to light following her ED visit.

This served as a learning experience for me – coming to a diagnosis in this case when the presentation was completely different from what was actually going on, and then connecting all the dots in the history (warfarin, chronic cough) and the physical examination (presence of a tender palpable lump in the absence of trauma) and ultimately finding out the mystery of the sudden lump, and then reaching a management plan that should have been so easy and straightforward, but really wasn’t due to the patient’s unique situation.

A day full of bizarres

In any particular shift, there is a chance you will get to see a patient which an ‘unusual’ or downright weird presentation. Often it is a perception problem on the part of the patient, and usually things are amenable to reassurance and counselling. This particular shift was ‘unusual’ for a number of reasons: the sheer number of ‘unusual’ presentations packed into a single shift, and the distinct lack of faith in my *ahem* reassurances.

Case in point A – 28 year old female walks in to the department with sensation of a foreign body stuck in her throat. Fair enough, seems legit. She then proceeded to tell me how she had had some bacon last night (yes, more than 12 hours back) and she felt that it was too hard, and very chewy and when she swallowed it she felt as though it had gotten stuck somewhere in her throat (so many questions, like why did you eat it if it was so hard and chewy and difficult to swallow and how big of a bite did you take? but of course what I really asked her was…). Have you eaten or drunk anything since then and she said oh yeah, I have had some toast this morning, and have been trying to drink lots of water to wash it down with. Any vomiting? No. Any chest or abdominal pain? No. Any previous history of having things stuck in your food pipe when you swallow? NO. OK, so what do are your actual symptoms? Well I felt all night as if this was stuck in my throat somewhere, and so I am having difficulty swallowing and also I think I am choking on it because I am finding it difficult to breathe. To which I had to explain to her the concept of the two different pipes, one for the airway and a separate one for swallowing food and drink. I asked her if she had had a cough at all, to which she replied in the negative. I tried to reassure her that had anything gone down the wrong pipe she would not have been sitting here comfortably talking to me the next day, she would be quite distressed and, quite frankly – choking! She just stared at me as if I didn’t know what I was talking about. Anyway, needless to say, she didn’t buy my reassurances, and said she wanted me to look down her throat and pull it out. I tried convincing her that everything seemed to be clinically alright and there seemed to be no indication of anything stuck anywhere (except me in this situation!) but she was having none of it. I excused myself, and discussed it with my consultant, who agreed there didn’t seem to be any indication for further assessment, but advised me to speak to ENT, and whatever they say I could use to reassure the patient. I spoke to ENT who very kindly understood my predicament and volunteered to come down and speak to the patient themselves. They were also of the opinion that there was nothing in her throat that should not have been there, but they offered to scope her, and guess what they found?


Yup. That’s right. No foreign body in her throat. And she very happily went home after that.

My next patient was by far the 2nd most bizarre occurrence of the day. Young 30 something male, walked into the department with an ‘unusual’ complaint. More of a request. He was known to have a hydrocele (a collection of fluid in the lining of the testicle, correctible with a small surgical procedure), and was waiting for an appointment for it to be surgically corrected. He missed his appointment for surgery for whatever reasons, and – get this! – he thought he would come in to ED to, and I quote: ‘Get it sorted today.’ *unquote*
I asked him if the condition had changed in any way or he had any new symptoms. No. Any fever or discharge? No. Any pain? a discomfort, yes but no actual pain, the discomfort had been going on for months now. Any abdominal pain? No. Any problems passing urine? No.
Well then I asked him quite frankly why he had come in to ED today? And he explained to me that he didn’t come in to hospital for himself today. His wife was in labour and he was just waiting to hear the good news, so he thought while he was waiting, he could pop in to ED to ‘get it sorted’. I explained to him that A) this wasn’t a case for the ED; B) I couldn’t give him an appointment for surgery even if I tried; C) did he think this was like a McDonald’s drive-thru? walk in to the ED, get an invasive surgical procedure done, walk right out? I examined him and assessed him fully, but I wasted no time in letting him know that the A&E was for exactly what it stands for: Accident and/or Emergency. I referred him back to his GP to sort out the appointment for him, possibly after his wife’s delivery. And I tried very hard not to blog about it then and there!

My third case (like I said, it was a series of bizarres, I kept waiting for someone to say ‘surprise! you’re on candid camera!) was that of an older female, in her late 50s, early 60s – who came in with a 9 week history of headache. Yes, NINE weeks. Gradually worsening, associated for the past 1 week with worsening neck pain and for the past 3 days with dizziness, nausea and vomiting, and that evening, she had gotten up off the toilet, felt very dizzy, walked out into her living area, and proceeded to lose consciousness for 10 whole minutes, unwitnessed but found by her husband who was in the next room and heard her fall. She now complained of feeling her legs were weak and numb, and that she couldn’t  moved her lower limbs of her own accord at all. She denied any back pain, there were no obvious signs of a head injury, and her sensations and power seemed to be intact, though generally weak in all muscle groups and not just the legs. Very non specific, but I discussed with my registrar the need for CT scan of her head. Oh, and she said she was worried because her mother had passed away at a young age due to a brain tumor. My registrar was reluctant to approve the CT head, but I suggested since I will document that this was long standing headaches, with sudden worsening, associated with loss of consciousness and some degree of neurological findings (however subjective they might be) that it would warrant a scan. It was then approved, and we got the CT scan sorted, trying to rule out a brain bleed. The scan was done, looked grossly normal, and per the medical guidelines, since a normal CT scan did not rule out a bleed completely, we admitted her under the medical specialty for observation and a lumbar puncture, which would check the fluid around the brain and spinal cord for evidence of the bleed, should there have been any. After the scan, as I explained all this to the patient, she became a bit nervous and looked visibly anxious at the prospect of a needle in her spine to extract fluid.
And as I stepped out of the cubicle and moved on to my next patient, I saw that, lo and behold, her lower leg weakness was miraculously cured as she got out of the bed ON HER OWN and then walked out for a cigarette. Sigh. She self-discharged herself after that, and walked out of the A&E on her own two fully recovered and recuperated legs. Fully cured of the headache and no signs of any of the weakness from previous. That wasn’t a waste of resources at all, was it?

Backpainslashshoulderinjury – what?

An interesting thing happened today while on shift. I saw a patient, who’s card told me this was a 60-something year old female, who had recently been seen around 2 weeks back in ED following a fall, resulting in a fractured humerus (upper end, basically a fracture of the shoulder) and had presented today with a few days history of lower back pain which was very severe. As I walked to the waiting area to call her in for my assessment, I began making a plan in my head of what I needed to rule out: was this new back pain unrelated to her prior fall, or was this a consequence of some missed injury from that fall? I called out her name and this lady wrapped in a huge jacket (loosely draped over her shoulders because of – presumably – the shoulder fracture) got up from one of the waiting area chairs and walked in behind me, slightly tilted towards the right, and walking at an angle, as if holding herself to avoid pain. We walked into a nearby cubicle to be examined; I introduced myself and asked her what had brought her to ED.

I noticed as she walked in and sat herself on the trolley, she required help with the jacket; she allowed me to help her out of it, which made her predicament apparent: She was not wearing a sling on her arm; it was dangling by her side (this was the arm that had the fracture in the upper part of the humerus, or upper arm bone forming the shoulder joint) – the hand appeared slightly swollen, as it would be from a long period of dangling, gravity would do the rest. I asked her where her sling was, and she mentioned that it had gotten dirty a few days back, and had been meaning to wash it but hadn’t gotten round to it. She told me the arm or shoulder wasn’t the problem, she was here today because her back hurt. I started asking her about the back pain (when did it begin – 5 days back; did you injure yourself during the prior fall – No; did you have another fall? No. The pain just began a few days ago and has just gradually worsened).

At this point she tried to shuffle backward in the trolley to get to a more comfortable position, and was unable to use her dangling arm. I couldn’t stand it any longer, so after I helped her get comfortable, I excused myself to go get her a new sling. I put her arm in the sling, and as she let the arm relax in the sling, her expression changed from one of long-standing pain and discomfort, to one of relief and comfort – ‘Doctor, you have somehow cured by back pain as well, I feel no pain in my back!’ I told her that very likely what had happened was that due to the painful left shoulder (which had been getting more painful because it was dangling beside her body as she walked around, rather than resting in a sling so her shoulder muscled could relax and allow the bones to heal) she was holding herself extremely taut in an uncomfortable abnormal posture, the only way to counteract or even avoid the pain of the shoulder – whether consciously or subconsciously – and that posture had caused her back to begin hurting as her back was being twisted into an abnormal position. The muscles of her back had been protesting, and now that she had put the shoulder to rest appropriately, it had caused her to relax in her posture – thereby causing her discomfort to disappear. She was raring to go home, but I still told her I had to examine her back, make sure we hadn’t missed anything else. There was no tenderness or bruising anywhere on her back, or any part of the bony prominences of her spine. I also assessed the neurovascular status of the limb that had been affected by the fracture – she was lucky there was still no distal neurovascular compromise.

Where she had required help to get comfortable into the trolley, she stood up on her own this time, without any support, bent over to pick up her bag from the floor with her good hand, thanked me for my time, and went home. I asked her if she required any pain relief, she waved the idea away as she walked off, saying ‘You’ve fixed me, Doc!’ She seemed like a completely changed woman; from the haggard, appears-to-be-in-pain-as-she-walked-into-the-exam-room old lady to the almost-bouncing-out-of-the-same-exam-room smiling chatting lady; the transformation was amazing to behold.

Just goes to show, always dot your ‘i’s and cross your ‘t’s, and never take anything for granted: you never know when the back pain that you think is something straightforward and expected turns out to be a not-so-straightforward posture issue resulting from an inadequately managed shoulder fracture.