ER Intern: ER Rotator Month-- Incidental Findings

So something I have been learning a whole lot about that seems to be a troublesome topic for many a new doctors, especially in the ER -- is what to do with indicidental findings.  How far do you go into a workup for something that the patient did not come in complaining about?

There is no awesome straight forward answer because many times patients don't know what is important, especially when they are scared or really sick. Who cares about that cat bite a week ago when the patient has a headache?  WE DO, but the patients don't understand that the bacteria from the cat bite went through their bone and infected not just the bone but their blood stream with is causing them to have a headache and be admitted to the hospital.  It is this simple problem that separates a physician from a medical student or intern. What is really important and to some degree what are the right questions to be asking?  This is the "art" of medicine you keep hearing so much about.

Its also something I keep running into as a new physician that makes me look around helplessly. These are things that very few studies have been published on and very few discussions in medical school or residency discuss. The problem with these is generally they aren't a big deal and can cloud your judgement with what the patient is complaining about now. But there are always exceptions especially when the incidental finding is sorta a big deal.

Milliary TB

So here are a few random cases to give you an idea.  I had a gentleman come in complaining of leg and arm pain with a small amount of dyspnea. He is very concerned about his pain and he knows he has a kind of arthritis. The man is about 50ish and is very lean and tall (some would say Marfaniod). Despite this joint pain problem, the real reason his doctor sent him to the ER is that his HR is 45 as I am looking at the monitor. He does not have a history of this and he is not a great athlete.  The patient could give a rat's ass about his HR, he just knows that he's a bit dizzy because the pain in his joints gets to him and he wants something for this joint pain. You can't get him off the freakin subject.  So I order up a cardiac workup, trying to figure out what to do with guy and completely frustrated that I can't get him off the topic of his joint pain. I even throw in a little 800 Ibuprofen medication when I put in orders to help him out.  Anyhow, the chest xray comes back and is this.... I know its hard to see but you can see many tiny nodules scattered throughout the lungs in both fields. And I check the radiologists read just to seek their opinion, yep.... Milliary TB. Uh.... talk about a hell of an incidental finding! So what do I do with this guy now? Obviously I can't just let him go home. Still have no idea why his heart rate is in the 40s, but he has no chest pain and is complaining of joint pain. Alright well TB can go into joints, so I do a generalized xray of a few of his extremities and all it shows is some degenerative changes from real arthritis.  So after some discussion with attending, we decided to do a CT scan of chest to confirm this TB and also see if maybe the TB spread to the heart which would cause his low HR. Maybe.... Alright so we're fishing but obviously this guy is a crazy mystery case. So CT comes back clean other than milliary TB in the lungs.  So I admit him and hope that the internal med folks can figure out what the hell....

There was another guy who was rather cachetic looking came in presenting of some headache. He was older and really not talking much to us, he was a transfer case and didn't have any paperwork for us. So when I talked a little about his headache it was like pulling teeth to get him to tell me any

information. But then I did an abdominal exam.... Oh wait sir, how long have these nodules been here? "Oh yeah... i forgot to tell you. I have stage IV liver cancer and am still on chemo. But also I am a full code."  Yeah! sorta a big thing to know! This guy was suddenly a chatterbox. He even asked me for a rice crispy treat, which i eventually caved, as you can see from the picture. Talk about a crazy finding tho! We immediately were able to treat his headache and nausea vomiting better because we knew it was from chemo. Although I felt sad leaving the room knowing that with tumors like that, he probably wasn't going to make it too much longer. :(  Its horrible to see those kinda patients.

Another weird case was someone coming in complaining of abdominal pain. The guy obviously is having a reoccurence of his pancreatitits since his lipase is 1476. But for some weird reason he is also anemic and since I'm learning the computer ordering system I decide to try the order set, which is a series of standard orders for one complaint. (for example there is an order set for pneumonia or chest pain, etc).  I order up his anemia workup because well he's obviously gunna be admitted. About oh I dunno 7 hours later the intern for internal medicine calls my phone and wants to come talk to me. She's all excited and wants to "pick my brain" and i'm like sure.... So she wants to know how I knew to order the malaria test on this guy because it came back positive! Say what?! Apparently, all the internal med people are all real impressed with me now, which is ironic since all i did was use the order set for anemia.  I told her I didn't think of it and it wasn't my genius. But moral of the story is... USE ORDER SETS. People will think you're smart.

On another randomly intriguing topic. There was a study recently published that we chatted about in conference the other day. It was on "gestalt" this magical ability of a doctor to have a gut feeling about if a pt is sick or really what their diagnosis is. Its what makes doctors keep ordering tests when all the usual tests are negative.  I guess a study actually looked at the accuracy of gestalt in the ER about PEs.  And Interns have a gestalt accuracy of pt having a PE about 71% and Attendings have about 78% accuracy.  I find this interesting and also weird that somebody actually studied this....
now I must acquire another 7% gestalt.... which scares me because it must be one heck of a big 7%.