Fooled

Patients can be tricky little buggers sometimes – they like to trip you up.

We were sent to a middle-aged woman experiencing difficulty in breathing. We arrived and I did my usual examination and history taking.

Here is what I learnt.

  • She had difficulty in breathing.
  • She had a cough.
  • She had a fast pulse.
  • She was coughing up a bit of frothy white sputum.
  • Her lungs sounded clear, no sign of infection.
  • She'd recently had a long haul flight.
  • She was a smoker.
  • She wasn't on the contraceptive pill.
  • She didn't have a high temperature.
  • She had a pain in her chest that wasn't made worse by her breathing.
  • She had a fairly low oxygen saturation.
  • She had deep 'S' waves in lead I.

All of which made me think that there was a possibility that she could be having a pulmonary embolism – this is a life-threatening emergency and needs rapid treatment at a hospital.

So we carried her downstairs, did an ECG (where we discovered the deep S waves – something that is one third of the changes that occur in a pulmonary embolism), and 'blue lighted' her into hospital.

After some investigation she was found to have a kidney stone.

A kidney stone?

Now, I've seen a lot of kidney stones in my time. None of them ever presented like this. With a kidney stone you get abdominal pain, back pain, you tend to writhe around on the trolley. You don't have a cough, chest pain, reduced oxygen levels and an altered ECG. There was nothing, absolutely nothing, about her condition that suggested a kidney stone.

But it just shows you how easily you can be 'tricked' by the examination and history of the patient. It's why I have a fairly low benchmark before I 'blue light' a patient to hospital. Even if it's just something that my subconscious has picked up I'll 'blue' them in – I can always find a justification to the hospital as to why I've done so.

“Treat for the worst, hope for the best”, it's how I get to sleep at night without worrying that I've let someone die because I haven't treated them seriously.

I'm sure everyone who works in healthcare has a similar story about how an atypical patient presentation has tripped them up. Feel free to tell me about it in the comments.

7 thoughts on “Fooled”

  1. Similar story to the above during a weekend call to an approximately 45 year old male. The presenting complaint was lower back pain since two days with some radiation to the legs, no signs for neurologic or muscular origin, normal pulse and BP, slightly elevated temperature, no mass palpable in his abdomen or groin although some pain was inflicted by deep midabdominal palpation. Normal urine sample. Non-smoker, not obese, no relevant history. He was also pacing around the room and the pain hadn't responded to a dose of morphine given by antoher GP the night before, we were the third GP visiting in those 48 hours.Consulted a vascular surgeon who stated that it couldn't be a ruptured AAA due to the fact that he was already having symptoms for two days and was hemodynamically stable, he thought that it could be diverticulitis. Nevertheless sent him to the hospital with a note stating the suspicion of an AAA, radiologist was unpleasantly surprised to see a dissection of the aorta from the bifurcation up to the thoracal part…

    He actually survived the following surgery and was back at home in two weeks.

    Although he had lower back pain there were no other symptoms pointing in the direction of an AAA besides the pacing and the non-response to analgesia.

  2. Job a couple of weeks ago. 90 years old gent rang 999 for an ambulance to assist him as he had fallen from bed and was on the floor. Not ill or injured – purely wanted assistance, and bearing in mind he had rung us himself. Not surprisingly, the call was categorized as a Green (ie low priority). Notwithstanding the colour of the call we sent on it straight away. The call was only a few minutes from the amb stn that the amb went from. When the crew got there they got no reponse at the door, and it was locked from the inside so we called the police. They arrived pretty sharpish and effected entry.The crew went upstairs to the bedroom, and found the elderly gentleman on the floor. Dead. No idea what happened, but it tends to make you thinkd about the AMPDS system we use. When the tape of the call was listened to, the gentleman was in no distress, and sounded perfectly happy that he would get some help asap.

  3. Had a night call (yes, some GPs still do them, although this was a while ago!) to a very obese gentleman in his fifties who was complaining of severe pain in the LIF and groin/scrotum, which was severe and colicky in nature. He was very restless and pacing around the room. He denied any chest or back pain and was not SOB.His T, P and BP were stable, chest was clear and he couldn't provide a urine sample at the time and appeared clammy due to the pain rather than clinically shocked. His abdomen was so obese it was impossible to palpate anything significant and his femoral pulses were intact. Thought he may be having renal colic with the stone impacted in the lower third of the ureter and sent him in to the RSO regardless, who concurred with the diagnosis after various investigations.

    The gentleman collapsed and died four hours later with a ruptured AAA. I have now seen this presentation three times – renal colic patients tend to roll around on the bed – all three of these paced around the room, so beware! The only pointers to the diagnossis were the pacing (another colleague has reported this also), size of his abdomen, which may have been distended as well as grossly obese (he was a patient of another practice, so didn't know him personally)and the lack of response to the Omnopon pain relief he was given by the hospital (although personally would have used pethidine or diclofenac). So glad I did not just give him analgesia, antibiotics and instructions to increase fluid intake, as the RSO had originally refused the admission due to the usual lack of available beds.

  4. I work on a retrieval service, i work on the principle of plan for the worst, and hope for the best… sadly with some of the people i go out with on a job, the “hope for the best” bit takes on a completely different meaning 🙂

  5. Poor old guy, but at least he didn't have an ugly (and pointless) resuscitation, and probably signed out believing he was okay.

  6. About 6 months ago, I came onto a night shift (I'm a nurse in an MAU) and one of my patients was a young British African man, who had been admitted, funnily enough with a suspected kidney stone. He was complaining of severe abdominal pain, back ache, difficultly passing urine and was clammy. Obs wise he was stable with nothing out of the ordinary, though slightly on the cold side, around 35 degrees. dr's had seen him, impressions was ? kidney stone, plan, KUB with possible ultrasound if needed, and pain relief. An hour later, my patient was writhing around in bed, and was sweating absolutely buckets. Temp now, tympanically was 33.4. Rectally, 34.5. Otherwise obs still normal, sats 98% on air, BP 130/70, pulse 65, resp rate 18. However, GCS was a bit tricky, if you did it sloppily you could get about 11, if you really tried GCS was 15. By this point I was a little concerned. My inner 'something isn't right here' feeling had gone into overdrive and I was starting to annoy the drs with my constant, 'this pt needs reviewing, something isn't right'. They didn't agree, they felt he needed more pain relief. 10mg IV morphine settled him for 5 minutes, then he was writhing around the bed again, this time crawling onto the floor from his hi-lo bed we had had to put him on because he was so agitated. Myself and my colleague had come to the conclusion that although he was supposed to have a kidney stone, he had something neurological going on as well – as my colleague descriptively called it, he had 'brain itch'.Bizarrely, again, although his temp was still low all other basic obs were still normal although by now his GCS was 5 and he was obviously extending when he was subjected to painful stimuli. ITU came and reviewed at this point, and his was the quickest transfer I have seen to ITU where he was tubed on arrival. They took him for a CT scan where he was found to have severe cerebral oedema. He coned and died at 3.30am that morning. An LP they did showed he had meningitis. It surprised everyone I think, because it was such an atypical presentation, no neck pain, no photophobia, no high temperature or rash, no headache (not initially anyway); nothing that indicated he had meningitis. Its taught me a lesson anyway, things are never quite what they seem! This is a situation will stay with me though, and everyone else who was involved.

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