Disposition and Patient Expectations

Case #1: 48 year old female presents with chest tightness, palpitations, and SBP > 200. Work-up is negative, including Cardiac Enzymes x 2, symptoms have resolved, and BP has "normalized". The patient asks the student (me), if she can go home.

Case #2: 31 year old female with history of surgically operated prolactinoma presents with recurrence of headaches, galactorrhea, possible bitemporal hemianopia, and dysmenorrhea (remember prolactinoma should cause amennorhea). A prolactin level is 3,900, MRI shows a 3 cm tumor pressing on the optic chiasm, and transvaginal ultrasound revealed endometrial polyps. The patient asks the student how soon before she moves to a room upstairs.

Tapa: Creating patient expectations for disposition before a definitive plan has been finalized can give patients false hope. In the aforementioned scenarios, the patient in the first case was kept overnight for observation with a stress echo in the morning, and the patient in the second case was discharged home with follow-up to Neuroendocrinology clinic and her gynecologist.

It is important to have an open relationship with your patients, and be honest about their disposition status. If you are unsure of a patient's disposition, do not offer them a definitive plan until you have discussed it with the primary (admitting/consulting) team.

Another important take home message can be gained from these examples. Mistakes will happen. They are inevitable in the learning curve of medicine. As doctors/students we must recognize these humbling moments and be honest and open with our patients. Numerous studies have shown that patient's value honesty in their physicians, and that patient care is not just about doing what's right for the patient, but also admitting when we are wrong.

Shoulder Dislocation

Case: 29 year old female dislocated L shoulder while swimming at lake.

Tapa: When assessing dislocations, you want to make sure you document neurovascular function prior to any therapeutic measures. With a shoulder dislocation it is important to check axillary nerve function. Sensation can be assessed over the deltoid, and motor function can be attempted with abduction.

X-Rays in at least 2 planes should be taken to ensure you have localized the dislocation correctly (over 90% of shoulder dislocations are anterior).

Left: Scapular Y-View showing an anterior dislocation.

There are numerous techniques used to for anterior shoulder reductions. The following video link from the good folks at Vanderbilt University illustrates a few of them: http://vimeo.com/8605660

After you believe the shoulder has been reduced, a simple test you can perform is to see if the patient can use their affected arm to reach across and touch their opposing shoulder. If they are successful, there is a good chance their arm has been successfully reduced. Post-reduction x-rays may be obtained to confirm placement.

The patient's arm should be placed in a sling, and the patient should follow up at an orthopedic clinic. It is important to instruct the patient that without physical therapy or surgery, the shoulder becomes easier to dislocate each time thereafter.