Normally, I prefer interesting, sick cases over the routine stuff. Not between the hours of 11pm and 4am though.  Not when they come in all at once. Not when I am by myself on the overnight shift.  I’ll take some regular ‘ole CHF any day over:

1. Sigmoid sinsus thrombosis in someone who randomly fell and hit their head.

2. Severe hypocalcaemia from an overenthusiastic thyroidectomy with carpoedal spasm, seizures, and strabismus.

3. A baby with intussusception

4. A young man with likely toxic shock syndrome from God-know’s where.

5. A woman with a big ball of half chewed spagetti and Italian bread lodged in her esophagus.

6. A guy with a recurrent head bleed that no one can figure out what the cause is – despite massive MRI and angiographical workups.

7. A guy with a giant thrombosed haemorrhoid – well, that one was cool. I incised it and got the mother of all clots out.

Me: “Sir, I notice you are here for testicular pain and swelling as well as a discharge from your penis”

26 year old normal appearing male: “Yeah, for the last week there’s pus and blood coming out in my semen when I ejaculate.”

Me: “I see. I presume you are sexually active? Have you had unprotected sex?”

Pt: “Yeah, three weeks ago  – but then nothing til last night when I met a new girl”

Me: “You had unprotected sex with a woman knowing you were ejaculating pus and blood?!?!?”

Pt: “Yeah, I know that’s kinda bad,  but at least I didn’t do it in her mouth.”

Me: “That’s still bad” (while staving off the urge to vomit)

There is nothing worse than trying to see through the craziness of people to determine if they are really sick – or just having a flare of nuttiness.  Kinda like how it’s so hard to deal with drug seekers – because you know they are seekers but perhaps just this once, they actually have something “real” going on.

People that are all anxious and nutty are very hard to get a history from. They exaggerate things, they leave out important things and over-emphasize things that are unrelated. They may have tachycardia and other objective findings that could indicate a serious underlying medical process.  I personally consider diagnosing things in these people, without taking a shotgun approach to all of them and ordering mega-workups, to be one of the most challenging aspects of my job.

Recently we’ve had a string of crayzee young women (not sure why it’s just women) who’ve been though giant workups for abdominal pain and vomiting.  You name it, the study has been done on them.  CT’s, Ultrasounds, EGD’s and Colonoscopies, extensive blood testing, seeing “peristalsis specialists” (I did not even know they existed) have all been done and nothing concrete is found.  Clearly there is a psych component to many of these patients and a few are overt drug seekers.  Their management is very difficult since they come in screaming, wanting drugs, retching everywhere, demanding calls to their specialists, hitting the call be q5 minutes, etc.   The other day, I felt like I was diagnosing a new one with this ill defined psycho-motility-reverse peristalsis syndrome.  The sad thing is that she was only 17.  She had all the personality characteristics of it – melodrama, dying swan, Scarlett O’Hara-esque, etc.  She’d had several episodes of the symptoms before that had always resolved after a day or so but  but came into the ER for the first time on that evening.   I almost decided just to do a few blood tests, give some meds  and re-assurance and then refer her for outpatient work up. However, I felt I was able to tease a little INVOLUNTARY guarding out of her from her otherwise histrionic abdominal examination.  I said to myself – “I’m going to order a CT and it’s probably going to be negative and I’ll have given her unnecessary radiation”.  But I just felt that little spidey-sense tingling.

Anyway, I signed out the case to the overnight doc when I left at 1am, telling him “I think we have a new Mary Smith * on our hands”.   I was sure it was going to be negative and that he’d have trouble getting her discharged. The annoying co-dependent mother that was with her did not help the situation. Well, imagine my surprise when I saw the doc next and he told me she had a big fat case of appendicitis!   I was like “Thank God she had something real that was solvable!”  Who knows, she might be back with nonsense but hopefully not.  Hopefully her nuttiness just came out because she had a real problem.  Never ignore your spidey sense.

* – the fake name of a regular cyclic-vomiter that comes in every week