As we say – don’t look at a patient with blinders on. In other words, although common things are common and you don’t need to do a huge work up on every one just to avoid a lawsuit, there are times you need to look a little more widely to find a diagnosis. The other night I saw that a patient was being triaged at 4 am with “bilateral hand pain” with a history of carpel tunnel syndrome. I mean come on, carpel tunnel pain at 4am? Please. Well, when I was interviewing her she also started telling me about all sorts of other complaints – which at first annoyed me even further. However, they seemed to fit into a pattern of sorts…. weight gain over two months, fluid retention in the face and legs, constipation, dry skin, fatigue, etc. Her PMD attributed it to taking too much Motrin (co-incidentally the pain started worsening right at the same time as the other stuff was going on. In fact, she really had not had any problems with her carpel tunnel for about year). Her doc luckily had the forethought to order some lab tests – which were done in our hospital as an outpatient the day before(but the results were not yet known). I checked them and would you know it, she had a TSH of 115 and an almost undetectable T4 level. Severe, new onset, hypothyroidism. That was causing the swelling – which in turn was worsening the carpel tunnel. So, there you go – even though you are annoyed and it is 4am, you gotta keep your eyes and mind open.
Wow! Good going on the TSH level.
I had severe hypothyroidism (albiet secondary) and guess what else I had? Carpal tunnel, tested and proved by the neurologist. It went away about two weeks after I started thyroid meds. Go figure.
Kudos to you for checking into it! You saved that woman possibly days or weeks of pain!
TSH of 115! I didn’t realize it could get that high. So many new things to learn as a student. Thanks for sharing through your blog! I’ve quickly become a regular reader.
To play devil’s advocate, if you would have just discharged her with a “non-emergent medical problem” or a wrist brace or whatever, her PMD would have found out about the critical results in like 4 hours when the clinic opened anyway, ie. the PMD did the correct work-up and she made an extra unnecessary ER visit. She could have called the clinic at 0800 for sure.
Well, it was a Friday night so it would have had to wait til Monday. But, either way, I wound up discharging her after I called the endocrine guy on call. Started her on Synthroid and some pain meds. I guess the point is that she was not just your typical chronic-paineur with a sob story. She had a treatable condition and won’t likely need surgery at least.
[...] thoroughly interesting and challenging cases in the same shift – one I posted on two days ago HERE. This is the second one. Ultimately, they are related, although from their presentations, you would [...]
Good catch, but a 4AM. Did you call her doctor at 4am and tell him the good news? I am sure that the lab had an alert value to call the ordering physician and he was probably going to call her on Monday morning.
I am unsure why the PMD did not at least give the woman some pain meds to get her over the weekend.