Looking for advice on a case

um, aneurysm? Did she have a CT? DOesn't sound like enough investigating has been done.

The rectal bleeding could be hemorrhoids. Is it frank blood, burgandy, black?

Do you think it's psychosomatic because she's taking psyche meds? If so, that's dangerous.

pain could be a pinched disk/nerve stool may be unrelated

I agree with anurysm, or check her out for cholecystitis. If she is a nurse and Murphy's law is still in existence, it'll be an anurysm. The worst things happen to medical staff. And medical staff only get THAT SICK to show up those more knowledgeable than themselves and make them feel like idiots for missing it.

I agree with the above posts. Sounds more like a probable compressed nerve and or disc in the thoracic vertebrae, but the possibility of an aneurysm shouldn't be ruled out.. Rectal bleeding may or may not be related (like mentioned above, is it frank blood? bright red, dark, occurs with BM, or just bleeding???) Or, could be psychosomatic, however I wouldn't exclude anything untill the pt. had at least a CT scan...

tell the dr who is blowing her off that PERSISTANT RECTAL BLEEDING is not in her head!

I spoke with her PCP further, and he's treating her as a frequent flyer. He seems to think most of her complaints are psychosomatic. When I had her, I just wanted to make sure she didn't have an evolving cardiac issue, which seems to be ruled out with a normal ECG, but he PCP thinks she's malingering. I just wanted to make sure I CYA'ed myself. She seemed to be embelishing her complaints to me, the "bleeding was just an add-on c/o and she eventually told me that was going on for the past several months. Just wasn't sure if I was being "played" like a lot of my patients attempt to do, just to get sent home.

Thanks for your responses. I've been in Occ Health for 9 years now, and I know most of the "malingerers". My intuition was giving me the thought that she was "full of it", but you never know :)

( Just to make things more interesting, this place is, ummm... like a big DAY CARE, and She was giving me such strange unrelated c/o sx that I was leary about it. When her PCP returned my call, he pretty much said she was proboably just trying to get out of work. He said she is famous for it. She was just a new pt to me, so I wasn't sure how much to believe, and how much was just BS.

She is NOT a Nurse. She is a UAW worker at auto component plant. I've been here for almost the past 9 years, and you wouldn't believe the lame excuses I get in the hopes that I'll send them home. They are covered and perfectly safe from any disciplinary action if I send them home. My deciscion can't be questioned by anyone.

This is an article that came out a few weeks ago on abnormal bleeding and antidepressants. I'm not saying that this is what her problem is, but it should be investigated.

Antidepressants May Cause Abnormal Bleeding

Increased Uterine, Gastrointestinal Bleeding Noted Among New Users

By Kelli Miller Stacy

WebMD Medical News Reviewed By Brunilda Nazario, MD

on Monday, November 22, 2004

Nov. 22, 2004 -- People just starting an antidepressant should be aware that it may increase your risk of bleeding, according to new research.

Researchers say the risk of bleeding associated with antidepressants is due to the brain chemical serotonin, a chemical messenger that plays a role in depression and anxiety.

Most antidepressants affect serotonin. Some antidepressants, such as selective serotonin reuptake inhibitor (SSRI) antidepressants, including Paxil, Prozac, and Zoloft, affect this chemical more strongly than other antidepressants.

The finding is published in today's issue of The Archives of Internal Medicine.

In addition to affecting mood, serotonin also plays a role in blood clotting. Previous studies have shown an association between the use of SSRIs and abnormal bleeding, particularly excessive uterine bleeding and stomach and intestine bleeding. But the evidence has been considered inconclusive.

For the new study, Welmoed E. E. Meijer, PhD, and colleagues in The Netherlands examined 64,000 medical records of patients that had taken antidepressants. Patients were considered "new" users if they had a prescription for at least a year but no history of prior antidepressant use.

There were 196 cases of abnormal bleeding. Nearly half were hospitalized for abnormal uterine bleeding. Stomach and intestinal bleeding accounted for 16%, brain hemorrhages accounted for 10%, and abnormal bleeding in joints, nose bleeds, and bleeding within the bladder, accounted for almost one-fifth of bleeding requiring hospitalizations.

Risk of hospitalization increased with the use of drugs that more strongly affected serotonin. Antidepressants generally work by increasing exposure of serotonin and other chemicals to the brain cells.

Those patients taking antidepressants with the strongest affect on serotonin had a 2.6-fold higher risk of abnormal bleeding compared with those taking antidepressants with the lowest effect. Antidepressants with an intermediate effect nearly doubled the risk.

SSRI antidepressants with the greatest serotonin effect include Prozac, Zoloft, and Paxil. Anafranil, another type of antidepressant used to treat obsessive compulsive disorder, also has a strong effect. Antidepressants with an intermediate serotonin effect include Effexor and the SSRI antidepressant Celexa. Remeron, Serzone, Doxepin, and Wellbutrin have a low affect on serotonin.

This is a preliminary study based on medical records only. If you are taking an antidepressant, talk with your health care provider to discuss the benefits and any risks of your medication. Do not stop taking your antidepressant without first talking to your health care provider.

--------------------------------------------------------------------------------

SOURCES: Meijer, W. Archives of Internal Medicine, 2004; vol. 164: pp 2367-2370. News release, JAMA.

http://my.webmd.com/content/article/97/104189.htm

Ruling out cardiac issues with a simple ekg isn't enough because it only shows the heart actvity at rest, it can't really rule out coronary problems. EKG changes is one sign of heart problems but an ekg is only recording the electrical activity of the heart, not what the vessels look like or how the heart functions physically. A stress test, at least, would be something.

Symptoms of cardiac problems frequently present as strange and unrelated in women, especially young women.

I just think it's a bit dangerous to dismiss thoracic pain so readily.

And like someone else stated, bleeding from the rectum is not psychosomatic.

I guess I'm just used to the type of thoracic pain you're referring to turning out to be a dissecting thoracic aneurysm. If she described the pain as being a "tearing" or "ripping" pain, I'd have 911 on the line before she could finish the sentence..

So what do you say to this person regarding her complaints. I really really really don't mean to second-guess you, but what do you say to her?

i realy didn't know what to make of it. She seemed to be all over the spectrum, and her DR. wasn't any help at all. I called him because she had such strange sx and I didn't want to just rely on the ECG to rule out anything evloving. That's why I started this thread. I have quite a bit of experience in cardiac and neuro and was just at a loss. I wanted to get her Dr. in on it so I wasn't the one that just "blew her off". I told her that she really needed to have the rectal bleeding investigated more thouroughly, and to go to ER if the headache/back pain got sharper and more intense as the night went on.

What really made me wonder what was really going on, was how sure her Dr. was that she was just trying to get out of here for the night. But.... she had sx that I didn't feel comfortable just passing off as BS

Ruling out cardiac issues with a simple ekg isn't enough because it only shows the heart actvity at rest, it can't really rule out coronary problems. EKG changes is one sign of heart problems but an ekg is only recording the electrical activity of the heart, not what the vessels look like or how the heart functions physically. A stress test, at least, would be something.

Symptoms of cardiac problems frequently present as strange and unrelated in women, especially young women.

I just think it's a bit dangerous to dismiss thoracic pain so readily.

And like someone else stated, bleeding from the rectum is not psychosomatic.

I guess I'm just used to the type of thoracic pain you're referring to turning out to be a dissecting thoracic aneurysm. If she described the pain as being a "tearing" or "ripping" pain, I'd have 911 on the line before she could finish the sentence..

So what do you say to this person regarding her complaints. I really really really don't mean to second-guess you, but what do you say to her?

Wow, I surely don't envy you. You have great responsibility! Good for you for getting in touch with her MD. From what you've been able to tell us though, sounds like maybe he wanted the night off too? :rotfl:

I wonder why her Doc was so quick to label her. It seems that you would have seen her before if she were just trying to get out of work.I am in no way trying to offend,just a thought.