What would you think if you saw this patient? - page 3
Just curious to know what other nurses think. To me it sounds obvious, but maybe I'm missing something... Let's say you have a patient in an outpatient clinic with the following symptoms: he... Read More
Jul 14, '17What do his tonsils look like (does he have 'em?)? Is his breath foul smelling? Is he febrile? Does he C/O sore throat (Can he still write? Give any subjective information or insight at all?)?
Hmmmm ... maybe another MD to evaluate?
Jul 14, '17Quote from Caprica6I work in an outpatient primary care clinic...you would be surprised at the number of inappropriate walk-ins we get: chest pain, stroke s/s, acute vision loss, severe respiratory distress, MVA, broken bones, possible hemorrhages, domestic violence...the list could go on and on and on...
Some folks are (IMHO) embarrassed to go to an ER or don't think their symptoms are "serious" enough, can't afford an ambulance...
All we can do is triage and refer appropriately...often times we call 911. When the acute episode has resolved, I have a frank conversation with them regarding the use of both our clinic and EMS/ER in an effort to prevent any disastrous sequalae from inappropriate clinic access. Sometimes the conversation is well received, sometimes it's not...
I work in telephone triage with primary care clinics scattered all over town - we too get inappropriate calls, such as CP and wanting to schedule an appt in several days, acute abd S/S's, inability to void ... the list goes on and on. Many don't understand no matter how you try to spell it out kindly (and gently) that their S/S's just aren't appropriate for an office visit, or that we are not a hospital.
A coworker of mine took an early morning triage call one day: mom and her 31 mo old child were sitting down in the parking lot waiting for the clinic to open - he was having an acute asthma exacerbation and mom ran out of necessary inhalers. She wanted to know what time the clinic opened as she planned to be a walk-in ...
It's even harder when they want to be treated over the phone ...
Many days I cringe and say a little prayer to the universe ...
Jul 14, '17Regardless of whether it is a sudden onset or gradual onset problem, I would be concerned that the patient is at risk of airway loss/obstruction and possibly aspiration as he is unable to control saliva and may have an obstruction or airway swelling.
Jul 14, '17From the perspective of the ER, the vaunted palace of unlimited technology, resources, intuitive insight, and the ability to actually be responsible for decision making (when we don't turf it to the next level): This one maaaybeeee should come to us. But, I give the doc credit for courage. Several previous writers have asked about other symptoms that could justify his decision - tonsils, infection, etc. Patients do "drool" or spit because it hurts to swallow - not because they are unable to swallow. And most are talking when they tell me they can't talk.
Jul 14, '17Quote from macawakePersonally, first off I'd like to rule out epiglottitis. (It could be caused by infection or injury to the throat).
My first thought was epiglottits or tonsilar abscess,...either way,..get him out!
Jul 14, '17Quote from RobbiRNHaha - that is absolutely true! In fact after working in ED it's difficult to judge anything by reading someone's words online...you could present an apparent ESI 1/2 and we could all come up with plenty of scenarios where it'd be worth ESI 4 at the most. Situations involving what I like to call "vocal stridor" come to mind...Patients do "drool" or spit because it hurts to swallow - not because they are unable to swallow. And most are talking when they tell me they can't talk.
Something similar could indeed be the situation here.
Jul 14, '17Quote from RobbiRNCourageous or reckless?This one maaaybeeee should come to us. But, I give the doc credit for courage.
With the information available to us, it's in my opinion impossible to decide.
Patients do "drool" or spit because it hurts to swallow - not because they are unable to swallow. And most are talking when they tell me they can't talk.
Honestly the entire scenario described by OP seems a bit weird to me and I don't understand why the only options available were neurological or gastrointestinal. I'm having a hard time believing this was a real life example.
Several previous writers have asked about other symptoms that could justify his decision - tonsils, infection, etc.
Listen Robbi, I'm not ruling out that it could have been a throat infection of some kind but with the scant details provided by OP, I don't see how anyone could be confident that the patient's airway wasn't or wouldn't soon become seriously compromised. To me that definitely warrants a trip to the ER.
It would be very nice if OP could come back and offer some clarification.
Jul 14, '17If they are not able to swallow, are they aspirating and/or able to eat anything? I'd imagine a trip to the ER would be necessary if breathing problems developed. If a neurological check was done and there are no signs of stroke is he maybe thinking patient is having a side effect to a different medication? Perhaps a nerve problem? Curious to know if there was any kind of testing done to determine if bacteria was the cause (my mind just automatically goes to this)?
Robinul can cause dry mouth so he's probably thinking of giving this medication around meal times to reduce aspiration risk for now, that would be my guess. Seems like a temporary fix to me and without further testing or information I don't think I can say anything more as I'm already speculating. It sounds (to me) like the doctor must have more information that he's working on or at least a good idea of what's going on.
Jul 14, '17The only GI-related thing I can think of would be achalasia, which is the loss of myelin sheathing of the nerves of the esophagus, which causes a loss of peristaltic function in the esophagus (stomach and intestines retain peristaltic function) and the inability of the LES to open to allow food to pass from the esophagus to the stomach.
But most achalasia patients go 2-5 years with symptoms before they are properly diagnosed, and diagnosis requires radiologic and manometric confirmation. In the rare event that the clinic doctor had knowledge of what achalasia even was, in a patient with such advanced symptoms the proper course of action would be outpatient testing (timed barium swallow x-rays plus manometry) for confirmation of diagnosis while waiting the 8 weeks it's going to take to be seen as a new patient in a gastroenterology office.
Jul 14, '17Quote from hppygr8fulIt doesn't sound like a typical nursing school question to me.Sounds a bit like homework!
Jul 15, '17Well, I'd go with option C and do an exam. Young patient. A retropharyngeal abscess can present this way, rare diphtheria also, +4 abscessed tonsils. So what was the exam findings? You're really leaving out important stuff