The mismatched symptom

About an hour into my Sunday afternoon shift, I’m called by Anne, one of our most experienced nurses. She’s just triaged Michael Tufnell (all names changed), a 59-year-old brought in by ambulance. “He’s in Resus-B,” she tells me. “Most likely a triple-A.” I rush to the room to find Tufnell pale and panting. He looks terrible. The bedside monitor shows a pressure of 70 over 40. He’s sick. He’s complaining about severe abdominal pain and, as Anne warned, his abdomen and lower legs are mottled. At first glance, Tufnell does look like he has a ruptured aneurysm. His attending nurses have started two I.V.s, and fluids are infusing. My assistant, who’s been around long enough to know what I need, brings a requisition for a CT scan. I move to the head of the bed and introduce myself. Although in clear distress, Tufnell is able to speak and in my head I run through the A, B, and C of resuscitation. He passes airway and breathing, and regarding circulation, I already know he’s in trouble. I quickly read the triage note before asking questions: severe abdominal pain, shortness of breath, radiation to back, extremities cool, abdomen mottled, hypotensive, writhing in pain. “Have you ever been told that you have an aneurysm in your aorta?” "No,” he says. “Does the pain in your belly go to your back?” “I don’t know,” he says. “It hurts everywhere.” “Can we take him to CT?” his nurse says. “Just a sec.” There’s one word at the beginning of his triage note that doesn’t match: Diarrhea. And when I ask Tufnell what prompted him to call the ambulance, he tells me that for two days, he had terrible abdominal pain and diarrhea. Read: Solve my problem: How do I know when it’s time to retire? Ruptured aneurysms don’t cause diarrhea. They can certainly cause severe abdominal pain with radiation to the back, along with low blood pressure and physical signs matching Tufnell’s: abdominal tenderness, skin mottling, pallor. Just because he has diarrhea, it doesn’t mean that he doesn’t have a ruptured aneurysm as well. I could send him to CT immediately, but he’s unstable. I might have to start meds to support his blood pressure before they take him. I glance out of the room to the whiteboard and check the vascular surgeon on call. If it’s a ruptured aneurysm, he’ll have to go to the operating room immediately. I turn to my assistant: “Can you page the radiologist on call?” I turn my focus back to Tufnell. “Other than the abdominal pain and diarrhea, do you have any other symptoms?” “No,” he says. “That’s it. It got so bad today I couldn’t get out of bed.” “Do you have any other medical problems?” “High blood pressure and high cholesterol. The usual stuff. I was here a couple of months ago with pneumonia.” He points to a stuffed pillowcase in the corner of the room. “I brought my medications with me.” A paramedic lifts the bag onto a metal table and pulls out some toiletries and clothes, sifting through for pill bottles. She knows that a current medication list is a crucial part of a good history. “Have you ever had any surgeries?” “I had a brain tumour. But that was a long time ago when I was a kid.” “What kind of tumour?” “It wasn’t cancer,” he says. "A benign tumour?” “Yeah,” he says, “I guess so.” “Anything since? Any abdominal surgery?” A wave of pain hits him and he winces. “No, nothing.” If it were 20 years earlier, during my first years of practice, I would have sent him to the scanner immediately while waiting for the clerk to get his old paper charts from the dust-filled filing room. He has severe abdominal pain and low blood pressure. He’s going to the CT scanner sooner rather than later, but before he goes, I want to call the radiologist and let him know that the patient’s coming so that he can look at the scan right away when it’s done. I also want to give him the best story possible. I scurry out of the room and log on to a computer. His last admission was actually two months ago—pneumonia, treated with a week-long course of antibiotics, along with renal failure. I quickly consider that his diarrhea is related to the antibiotics (clostridum difficile) and that he may have a toxic megacolon, but it seems too far in the past. For such a short admission (two days), there are many notes, all several pages long and all similar. There are lines and lines of formatted medication lists, lab results and vital signs. Much of the information in these notes is auto-populated by macros that include as much (perhaps too much) information as possible. In each of these clinical notes, there is a table that details Tufnell’s urinalysis, and a table that details Tufnell’s CBC results. Mixed in with these and other test results are the physician narratives—the part of the note I find most useful. While the benefits of an electronic medical record far outweigh the drawbacks, we often see discharge summaries and instructions from a neighboring hospital that are pages and pages of information, most of which are irrelevant or useless. Read: Rounds: Doctors with a funny bone I scan Tufnell’s medication list and notice that along with his blood pressure and cholesterol medication, he’s on Desmopressin nasal spray. I remember that it’s used most commonly for diabetes insipidus, which can lead to severe dehydration. Maybe Tufnell has severe diarrhea secondary to foodborne or viral illness that has been compounded by water loss? I rush back into the room and ask why he takes his nasal spray. “It’s just a nasal spray, isn’t it?” he says. “I’ve been on it for as long as I can remember.” My assistant pops into the room, phone in out-stretched hand. “I have the radiologist.” I tell him the story, adding that the patient looks terrible. “He might be a ruptured AAA, but his chief complaint is diarrhea, so I don’t really think so.” “OK,” the radiologist says. “Send him.” Before he goes, I check back to the computer. I scan through a couple of his progress notes, and finally, click on his discharge summary from his last visit. I scroll through the lab results and the final line catches my eye: “Adrenal insufficiency, given stress dose of hydrocortisone.” Read: Reasons for joy: A reminder of the 10 classic reasons it's great to be a doctor I suddenly feel both smart and stupid. I return to the room and ask if Tufnell’s been able to take his medications for the past few days. “No,” he says. “I haven’t felt well enough.” I ask the nurses to give him intravenous steroids. “I think he’s in an adrenal crisis.” I explain it out loud, more for myself than anyone else. “He had brain surgery as a kid—it was a pituitary adenoma. So he has adrenal insufficiency—not primary adrenal insufficiency, his adrenal glands are alright, but secondary—he has no pituitary gland to stimulate them.” “I still think it’s a triple-A,” his nurse says. She might be right. He sure looks like a ruptured aneurysm. But we don’t see patients in adrenal crisis that often, and it’s probably a good mimic for a triple-A. Tufnell is rushed off to CT and the radiologist calls me before he’s returned to the ER. “I don’t see anything,” he says. “Not even colitis.” Read: Treating pediatric constipation: Here’s the poop It’s reassuring, but I’m still unsure, and I’m not sure how to confirm whether my suspicion is correct. But when he’s wheeled back into Resus-B, his blood pressure had normalized. I return to Tufnell’s bedside and put my masked lips to his ear, “Has anyone told you that if you’re ever really sick, you should let people know that you may need a shot of steroid?” "I’ve never heard that before,” he says. I feel smart when I discuss his case and transfer his care to the admitting doctor. I feel smart even though I missed the initial hints—the steroid pills he takes daily (hydrocortisone was listed right after hydrochlorothiazide, but in my hurry, I assumed it was topical, not oral), the clearly noted “transphenoidal resection of pituitary adenoma” in the first note I read. Unless the note had explicitly said stress dose of hydrocortisone in his discharge summary, I’m not sure I would have thought of it. Dr. Raj Waghmare is an ER physician in Newmarket, Ont.

The mismatched symptom

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