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(Emergency Room Sounds)
RAJ: A 27-year-old female presents to the ER with nausea, vomiting, and myalgia during flu season. Her symptoms began a few hours prior to her arrival in the ER. She is otherwise healthy, with no significant medical history.
DDX is a podcast by Figure 1, the knowledge-sharing app for doctors.
I’m Dr. Raj Bhardwaj. I’m a practicing emergency physician and your host.
Today’s case comes from an ER doc in Dallas, Texas.
HO: I Amy Ho, I am clinical faculty in emergency medicine.
RAJ: Dr. Ho was in the middle of an ER shift a couple years ago, at a different hospital than where she works now, when she picked up a patient who, upon first glance, looked relatively healthy.
(Emergency Room Sounds)
A quick note – The patient in this episode is represented by the voice of a professional standardized patient, like the ones used during clinical training and exams.
HO: When I got to the room, she was laying in the bed, she was young, thin, fairly fit, She had no real medical history. She was a little bit pale, a little bit gray. She wasn’t really moving around much at all actually. Like she kind of looked like a bowl of a wet noodles because she was kind of floppy. She looked like she was feeling really crummy. She told me that she was feeling really nauseous…
SP up: I’ve been vomiting since this morning and I just feel weak and achy all over. I had to leave work early because I just couldn’t function anymore. My co-workers said I should probably get checked out, so I came straight here.
HO: We gave her some Zofran just to help her feel not nauseous since it was her chief complaint. I ordered her some fluids. [..] And then we checked some basic labs … electrolytes to assess for dehydration or salt level, a basic blood count which gives us signs of infection. And then we also took a pregnancy test.
So, we did our initial assessment, the nurses come in, draw her blood, start her IV, start giving her medicines, and from our perspective we let her sit and see if she gets better over some time while we see some other patients.
RAJ: About an hour later, while most of the blood work was still pending, a nurse told Dr. Ho that the patient was complaining of heartburn-type pain in her stomach and chest
HO: So I ordered the patient some pepcid and I went back to go talk to her. She told me that she’s still pretty nauseous and that she was having some chest pain.
SP up: It feels like a burning feeling that’s going up into my chest from stomach and I also have a headache now.
HO: Told her, […] that maybe burning is from the vomiting And I also told her that we wanted to get an ekg just because she was having chest pain.
RAJ: Dr. Ho wasn’t particularly worried about the chest pain, the EKG was more of a precaution. But what did give her pause was that the patient’s condition seemed to be getting worse.
HO: By an hour in, I would expect her to start feeling a little better. The fact that she wasn’t feeling better was a little bit of a warning sign. So that’s what made me decide to go digging a little bit more
RAJ: So they did the EKG and Dr. Ho and her team saw something right away.
HO: We notice that she had what we call deep inverted t waves. So t-waves are a segment of the electric impulse that represents electric, like repolarization. And it’s something we look at when we’re looking for a ischemia
That really caught us.
So we, so we looped in the cardiologist.
RAJ: Dr. Ho and the cardiologist asked the patient more about her medical history. She told them she’d never had an EKG or any known heart issues or surgeries.
HO: But then, when we asked her about a family history and had anyone died of a heart attack or had heart issues, she did tell us that her mother passed away suddenly when she was really little
SP: But my mom didn’t have a heart attack. I don’t know what it was, but I know it was sudden and it had to do with her brain.
HO: The moment she said her mom had died when she was really young, that caught us – because young healthy people who die unexpectedly is always reason for concern. And especially when I’m sitting here with a young, healthy person with symptoms that aren’t what I thought they were initially.
RAJ: In that moment Dr. Ho realized that what they were seeing on the EKG maybe wasn’t related to her heart at all, but was actually a sign of something going on in her brain.
HO: So we now have changed our minds of what is going on with her ekg because the deep inverted t waves we saw on her ekg could symbolize an elevation of intracranial pressure.
We realized that maybe there’s a family history of a brain bleed and that’s actually what caused the passing of her mother, you know, nausea can actually be the first sign of a small brain bleed.
RAJ: At this point subarachnoid hemorrhage was racing up Dr. Ho’s DDx, but the only piece that didn’t fit was that the classic presenting symptom is a sudden onset thunderclap headache.
HO: And it was kind of happenstance or just good luck that around that time she volunteered for us that her chest pain was getting better with the pepcid, but that her head was really killing her. Because, you know, a couple of minutes ago she asked us for pain medicine for headache and we kind of ignored it, in all the rush of asking her all these other questions about her ekg and cardiac history. So now she told us, you know, hey, my chest is feeling a little better, but can I really have something for my headache? It’s really bothering me. she said that it was pulsating and throbbing. Now she was looking actually in pain, like she was scrunching up, her face. And she would lean over or she was holding her head in her hand and looked like her head was really, she said, killing her.
RAJ: They rush her in for a CT scan and CT angiogram and there it is…
HO: We see an obvious bleed on the CT.. A subarachnoid hemorrhage. Usually that type of hemorrhage is associated with an aneurysm. So on the ct angiogram, her anterior communicating artery had a little little blob on the side of it. And that was exactly what was bleeding and where the blood was coming from. And that was her aneurysm that ruptured.
My reaction was, uh, you know, holy crap.
We would’ve absolutely missed this.
RAJ: Dr. Ho paged the neurosurgery team and start prepping the patient for emergency surgery.
HO: As we’re rolling her back from ct, we told her that a lot of things were going to happen because we knew what was going on. We told her that you’re going to need surgery, you’re going to the icu and oh, by the way, this might be what happened to your mother.
RAJ: The neurosurgery team decided to do an endovascular coiling – a minimally invasive technique that doesn’t require cutting open the skull. Instead, they passed a catheter up through the groin into the anterior communicating artery where the bleed was.
HO: About sixty percent of patients with aneurysmal subarachnoid hemorrhages, which is exactly what she had, either die or have permanent disability.
RAJ: That didn’t happen with this patient.
HO: So she did really well actually. She went to the neuro icu that day. She got coiled a few hours later, and then full recovery and discharged within a couple days, um, which is pretty incredible […]
RAJ: Although this patient had a good outcome, Dr. Ho couldn’t shake how close she had come to missing the aneurysm entirely.
HO: I mean, we absolutely could have missed this and she absolutely could have just gone home and tried to sleep off the flu. She could have gone to bed and just not woken up.
RAJ: Looking back, Dr. Ho is grateful that the patient’s chest discomfort led her to do the EKG. The chest pain may have just been reflux related to the vomiting, but getting that EKG along with the family history and then the sudden severe headache is what led them to the aneurysm diagnosis.
HO: in this way, if we blew off her chest pain, as just reflux, we would’ve missed getting more history. That was really essential in finding out what was wrong with her.
RAJ: This case is also an example of when the “end of the bed test” that we’re taught to do can sometimes work against us. (We’ve all done it…. Stand at the end of the bed. Look at your patient. Do they look sick? Or not sick? How worried are you about them? All this leads to a “gestalt” - a general impression of what’s going on, bad… or not so bad. It’s when the doctor, with our experience, and our bias, becomes the diagnostic test… And just like any diagnostic test, the “end of the bed test” has limitations…)
HO: Emergency medicine is very skewed. We see a lot of very chronically ill people with, you know, life threatening issues as a result of those chronic diseases. So when we do see a young healthy person, It’s really easy to blow them off as just a cold, just a flu. I think women definitely are more prone to being blown off.
RAJ: There’s research to show that women, especially younger, relatively healthy women, can have an especially hard time getting doctors to take their pain and other symptoms seriously.
HO: So for this patient, the end of the bed test just passing by as young, healthy female, she looks nauseous, we’ll fix it, she’ll go home. No big deal. But then it’s really the spidey senses of, hey, this girl’s not getting so much better. She’s having this new symptom, maybe things are progressing that we really have to trust. Because that’s what led us to the ekg and ultimately, to her diagnosis.
Thanks to Dr. Amy Ho
This is DDX, a podcast from Figure 1 about how doctors learn. Figure 1 is an app that lets doctors share clinical images and knowledge with each other about difficult-to-diagnose cases. It is produced by Kalli Anderson, Kaija Siirala, Ann Lang and Zoe Robertson for Earshot Podcasts
Our executive producers are Jesse Brown and Corey Marr.
And our theme music is by Nathan Burley.
You can find full show notes, photos, references, related medical cases, and links to the research on gender and diagnosis at Figure 1 DOT com SLASH DDx.
I’m Dr. Raj Bhardwaj. You can follow me on Twitter at @RajBhardwajMD. Thanks for listening.