This was one of the patients I submitted for Nurse K’s Dr. No BS contest. By my calculations, I was the unofficial winner in said contest, but I don’t want to brag.
The case involves what one of my old mentors used to call his “Spidey Senses“. Something just doesn’t seem quite right. You can’t figure it out, but something tells you that you need to dig deeper. Most of the time, the Spidey Senses are just a false alarm and you end up performing what some people deem an “unnecessary” test. Hey, even Spiderman wasn’t always right. But in a select few cases, listening to your Spidey Senses (and sometimes ordering “unnecessary” tests), can help to make an important diagnosis.
Psych wonks may use the term “cognitive dissonance” to describe the Spidey Senses. I’m leaving the post title as “Spidey Senses” because prolly no one would read a post about cognitive dissonance and because I couldn’t find a cognitive dissonance picture.
A 50-year-old man came in with R shoulder pain for about a week. He was already going to a pain clinic for low back pain, and that day he went to the pain clinic for a re-check of his shoulder pain. The doctor at the clinic prescribed him Neurontin for his shoulder pain and the patient came to the emergency department because “that stuff doesn’t work.”
He said that his shoulder pain was bothering him so much that now his right side was killing him, too. In fact, he wouldn’t lay back on the bed because of the pain. His wife sat next to him helping to support him while he was sitting as he slumped over to the right side and didn’t answer many questions because he was in too much pain. The patient’s wife did most of the talking.
I have to admit that my initial impression of this gent was tainted by the whole pain clinic story.
Maybe he was coughing from his pack-and-a-half day smoking habit and strained a muscle in his chest wall.
Pain from a gallbladder attack can cause referred pain to the right shoulder when the inflamed gallbladder irritates the diaphragm. Maybe he’s having biliary colic.
Maybe he had a pneumothorax.
Maybe he was doing something he shouldn’t have been doing and injured his shoulder, but he didn’t want to tell me.
But come on, now. Pain so bad you can’t even talk to the person trying to help you? Call me skeptical.
The patient’s vital signs were all normal. His oxygen sats were normal. His exam was difficult to perform because he wouldn’t lay down so that I could examine his abdomen and he wouldn’t take deep breaths because it hurt too much. There was some serious pain transference going on there as well. His wife let out a “reverse hiss” any time that the patient moved.
We were able to do labs and his CBC, metabolic panel, and cardiac enzymes were all normal. I ended up having to give him IV morphine so that we could get an EKG and chest x-ray, both of which were also normal.
I also gave him some IV Valium and he began to feel better. At least he would lay on the stretcher and talk to me.
When I mentioned it to another person in the emergency department, that person said “What do you expect, you gave him his fix.”
Maybe I am just a sucker.
Then I re-examined him.
Heart still sounded normal.
His abdomen wasn’t too tender, so gallbladder disease was less likely. Besides, he had normal liver functions and WBC on his labs, and if he had acute cholecystitis for a week, his gallbladder would be gangrenous by now.
I listened to his lungs and now that he was able to take deeper breaths, there was a friction rub. Pleurisy. Great. This guy was acting like he was dying when he came in here because he was suffering from a simple case of pleurisy?
Enter Spidey Senses.
He was a smoker and he still had quite a bit of pain, so I figured “what the heck” and ordered a CT scan of his chest.
Bad doctor. Had I been applying the criteria advanced by the American College of Radiology – a group of non-clinicians making recommendations about how clinicians should practice medicine – I wouldn’t have performed the CT scan on the patient’s chest because the patient didn’t meet criteria for performing the CT scan.
Fortunately, my Spidey Senses won out.
CT result: Large right lower lobe pulmonary embolism with pulmonary infarct abutting diaphragm and right chest wall.
It took a good ten minutes for my heart to stop racing after reading that report. The patient’s right shoulder pain was from diaphragm irritation, but it was dead lung tissue irritating the diaphragm, not an inflamed gallbladder. His friction rub was being caused by the dead lung tissue irritating the lining of his chest wall.
Had I adhered to guidelines from the Choosing Wisely campaign and the American College of Radiology and avoided performing this “unnecessary” CT scan, the patient would probably be dead right now.
The most ironic part of the whole case was that I had to plead with the patient not to leave the hospital against medical advice.
He was a commercial crane operator and had a time-sensitive job that needed to be finished the following day. If he wasn’t there, all of the construction that depended on what he needed to do would be held up.
Finally, I asked him “If I called your boss and told him you were in the hospital and had a heart attack, do you think he’d understand?”
“Well, call your boss and tell him you had a ‘lung attack’ – it’s just as deadly.”
That must have set off his Spidey Senses.
“Guess I’m staying, then.”
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.