Clinicians hit dead ends on complex cases with contradictory guidelines
87 posts across 12 communities in the last 30 days; 57% from r/nursing.
“I very much thought the machine was broken. It was not. What's even crazier is we had to beg the doctor for a foley because he also didn't believe us and thought we were using the machine wrong. Anyways that was a first for me I never in my career seen someone retain THAT much…”
“Took my cat in for an entirely different issue and while we were there she heard a murmur. Recommended we do the proBNP test, and it unfortunately came back elevated. So now here I am facing the reality that my 5 year old perfect boy may have heart disease when all I took him in…”
“we had a similar thing at my old facility, they would hold meds for bp under 100 systolic but for beta blockers the cutoff was 90 i think. depends what the doc ordered really, there should be something in the mar or the care plan about when to hold and when to call. if theres…”
Doctors are struggling with diagnostic uncertainty and potential patient harm when dealing with complex or unusual medical presentations. They face frustration in quickly and accurately identifying the root cause of patient symptoms, leading to concerns about appropriate treatment and potential negative outcomes. The complaints highlight a need for better diagnostic tools and interdisciplinary collaboration.
SOURCES (60)
“Seeking input from vestibular PTs, or anyone more experienced with treating BPPV than me. I'd love to learn from you. Please tell me what you would have done in this case! I work on a med-surgical unit in a small rural hospital, and we often…”
“Hi. OP onc nurse here. Had a patient for the first time today that was given blood labeled as incompatible. Called the blood bank and there is an entire protocol for administering. An order needs placed by the physician to acknowledge. I can’t remember what it said exactly, but something along the lines as the patient has some type or lacking some type of protein, and only about 5% on donated blood could be an exact match. I was on edge the whole time they were there, but they got through the tr”
“I work on a telemetry floor as a new grad rn and have been thinking about this patient for a bit now. Male in his 60’s, A&Ox1-2, GCS 9. Family brought him in because he was showing signs of increasing weakness and LOA. I got in for night shift and all was going smoothly, same mentation as day shift, stable vital signs, no decreasing trends in BP or increase in HR. Patient was distended and resident ordered NG tube insertion. After putting in NG tube I noticed bright red blood and notified re”
“I’m a student and today I hung iv abx for the first time, I asked my professor about a hypothetical where what if a patient has a midline iv access as well as a picc line, the order we were looking at, didn’t specify which Iv to put it in. My pt only had the PICC, but if my patient theoretically had both, how would I know which one to put it in? submitted by /u/Frequent-Drawer-4367 [link] [comments]”
“New grad here. In dental school they didn’t necessarily give a guideline on what procedures / dental pain require T3s (we were just informed what order to increase med strength eg acetaminophen to ibu to t3). I work with different dentists who prescribe very differently (one will prescribe 20 tabs for endo pain before and even after rct completed, the other one only prescribes for surgical extractions). What procedures do you usually prescribe for? I work rural so I want to make sure I am not ov”
“I have a patient with lumbar radiculopathy who is post-laminectomy. She is followed by pain management. She used to be on Norco and failed a drug screen, which was positive for marijuana and benzos. Her prescription was changed to tramadol and she was started on Cymbalta and Lyrica. Epidural steroid injection done recently with no benefit. She’s being seen by Behavioral Health. She has written extensively through my chart to the pain management doctor berating him for not taking her pain serious”
“Hear me out. I’ve got a 60 yo patient with CKD 3b which has been pretty stable for 5+ years. She sees nephrology so maybe i just need to mind my own business. But over the years, i have never seen her nephrologist check her microalbumin to creatinine ratios. With as much as i have learned about albuminuria I am tempted to order UACRs and then treat with sglt2 if indicated. Already on ARB. Am I overstepping my bounds as her PCP when she already follows with nephrology? No judgement against her ne”
“Sounds like there's really no good answer for OP. I work children's flex ICU so go between all the icus and med surges of our children's hospital and none of them require an NG for placement (baring complications/no ph obviously.) It used to be required more but parents were complaining that they were expected to put them down at home without an X-ray so why weren't we. [re: Is x-ray verification always needed for NGT connected to suction]”
“Similar situation happened recently on a RRT I responded to. The nurse did complete proper procedure for removing the CVC. But, this patient that had been NPO suddenly vomitted and aspirated. Coding within 15 seconds. Sometimes things can be unpredictable. People come to the hospital because they are sick, and sick people commonly die. It’s okay to examine the situation and see what could have been done better BUT don’t let this delve into beating yourself up. [re: Unexpected freak accident happ”
“Send them an OE "article" on how to manage a common clinical scenario in their field while simultaneously asking for tailored recommendations for your patient. submitted by /u/Fun_Split_239 [link] [comments]”
“Labs all nml. Dc’d with recommendations to see derm, rheum, and w/u for vasculitis. Pt takes blood thinners EDIT: as a THIRD YEAR medical student in america, i’m interested if anyone here considered this as shingles LOL Reddit reached out offering me self care guidance? Which ever nurse did that, it just goes to show the differences between doctors and those that are not, are more than a few. Its blatant submitted by /u/ImprovementQuiet7402 [link] [comments]”
“really isn’t that dangerous if it’s an otherwise healthy person. but yeah septic hypotensive grampy might crump from emptying that bladder [re: Bladder scanned a patient today that had 3000ml]”
“I very much thought the machine was broken. It was not. What's even crazier is we had to beg the doctor for a foley because he also didn't believe us and thought we were using the machine wrong. Anyways that was a first for me I never in my career seen someone retain THAT much urine. Idk how it was even possible. submitted by /u/ZingierPond5471 [link] [comments]”
“I get the text, admit in Er Room 23. Chart check. First thing I see is interestingly a GI note. It mentions brpbr but okay to anticoagulate, IV ppi bid, and we'll see them tomorrow. That's weird. Next I see the triage note. It mentions the patient came in for shortness of breath and fatigue. He got a bunch of tests and now has moderate anemia. Also had a bruise. They ended up getting an ultrasound at urgent Care and that showed occlusive DVT. Also has an aki. Oh boy. This is going to be”
“Took my cat in for an entirely different issue and while we were there she heard a murmur. Recommended we do the proBNP test, and it unfortunately came back elevated. So now here I am facing the reality that my 5 year old perfect boy may have heart disease when all I took him in for was an infected nail. The wait list for a cardiologist appointment in my area is an average of 6 months. I'm still waiting for them to review the referral and call me. But that seems an awfully long time to wait”
“New attending and still have trouble deciding on Afib dispo unless slam dunk obvious. Obviously if rate can’t be controlled and on a drip, admit. Obviously if known history of Afib, hemodynamically stable, and rate easily controlled in ED, discharge. But what about the new onset 74 year old who is asymptomatic, hemodynamically stable, rate controlled in the ED, and wants to go home? What if she also has a new LBBB? I think I’ve discharged one new onset Afib in the past, but this was an otherwise”
“Forreal, plus these things are quickly entered by busy triage staff. I walked into a fresh ED case the other day and the triage reason was "arm pain." He rolled up his sleeves and had horrific cellulitis covering both arms [re: Are we serious]”
“I'm confused because different vets are saying these mean different things about her liver and dietary needs now. One is saying fatty liver, one is saying cancer. The abnormal readings only: SuperChem: AST (SGOT) 1,000 ALT (SGPT) 2,100 ALK PHOS 260 T. BILIRUBIN 0.7 Complete Blood Count: Platelet count 175 Neutrophils 9,800 / 83% Urinalysis: Protein 2+ Bilirubin 1+ Occult blood 2+ RBC 4-10 Species: Cat Age: 12 Sex/Neuter status: spayed Breed: Domestic shorthair Body weight: 11 lbs History/cli”
“we had a similar thing at my old facility, they would hold meds for bp under 100 systolic but for beta blockers the cutoff was 90 i think. depends what the doc ordered really, there should be something in the mar or the care plan about when to hold and when to call. if theres nothing written then its a problem, nurses cant just decide on their own to delay notifying the physician till next day if vitals are out of range. you could check the policy manual or ask the unit manager to clarify, somet”
“Is LTC allowed to have no parameters on beta blockers? Are they allowed to delay physician notification until the next day? submitted by /u/Worldly_Comparison89 [link] [comments]”
“dysphagia screens are the bane of every stroke program's existence. we KNOW they were assessed because if the patient can eat their obligatory turkey sammich without choking on it, they can swallow. unfortunately, the assessment has to be documented.”
“I correctly asserted a patient had Guillain-Barré syndrome (GBS) . Unfortunately, I can't think of an hysterical diagnosis. Sorry.”
“If your 40-year-old patient was "shot-gunning" beers in the parking lot just before checking in and reporting stroke symptoms, do you still have to complete the swallow screen with NIH? /s submitted by /u/amybpdx [link] [comments]”
“Hi everyone, new attending and came across the situation in the title. Patient is scheduled to see me for STD paperwork. I have seen her once. However, she has been seen by cardiology at least twice (maybe three times now) and is being treated for POTS by a cardiologist who has even recently prescribed fludrocortisone and ivabradine. I am always happy to help patients out, but in this situation isn’t it more appropriate for the physician managing the condition to fill out the paperwork? I know i”
“Hi Please help me understand the situation We incidentally found these renal values indicating CKD, when we visited the vet for one episode of blood in urine, which was found to be from an enlarged prostate. We also found that he has a solitary kidney. He is an intact male Blood pressure- 130 to 140 range SDMA - 24 Phosphorus - 3.9 mg/dl BUN -29.3 Crea -2.04 Serum potassium - 4.8 meq/L CBC, LFT - normal Urine protein creatinine ratio - 1.9 Urine protein +++ - 176 mg/dl , spermatozoa observed USG”
“the stryker manual itself says that helps with pulm hygiene but it doesn't actually offload for wounds. i looked because i was hoping it would tell me it would 😂😍”
Your patient on thinners submitted by /u/Rixy_pnw [link] [comments]
“Scenario: Pt with saddle PE, on oxygen and a bit of Levophed, but looks ok otherwise with good vitals. Needs thrombectomy, which your shop doesn’t do, so you call for transfer. Receiving facility has capability and capacity, but refused because “patient sounds too unstable” Are they allowed to do this? Doesn’t the decision for stability for transfer test with the sending physician? Further, if patient is informed of risk of deterioration but still wants transfer and signs consent, doesn’t this b”
“Switch to outpatient oncology (infusion). It is a never-ending cascade of new drugs, every week. It is actually a lot to keep up with, when you include oral chemo and all the new immunotherapy drugs.”
“Saw an elderly Parkinson’s patient today who normally has pretty normal BP, but his BP was really elevated when I took his vitals. He told me he’d been drinking water because he had a “seltzer” earlier. We rechecked his BP about halfway through the visit and it was still elevated, although he wasn’t having any other symptoms. Around that point I happened to look into his kitchen and noticed a couple of unopened White Claws sitting on the table. I brought one over and asked if this is what he had”
“Hi everyone, Just wondering how people handle situations like these where there seems to be a pretty obvious beneficial medication choice or change for the patient who follows with a specialist for a specific condition. An example: saw someone with HFrEF, on carvedilol 6.25 mg BID, losartan 25 mg daily, spironolactone 25 mg daily, and dapagliflozin 10 mg daily. Follows with cardiology in the same health system. On chart review can't figure out why patient isn't on Entresto. Hasn't tr”
“My floor is so anal about this, esp with chemo — we get tubing that connects to the primary below the alaris channel and add an arbitrary 25-50ml extra of VTBI so the entire chemo line is completely dry before it is taken down. Chemo lines are never reused and we want to make sure we are getting every last drop of that dose into the patient before their infusion is disconnected. Because of that training, this method has trickled over into other IV meds— almost everything is hung IVPB and most nu”
“I train in a highly defensive program where even asymptomatic BP of 190 gets referred to the ED from the clinic. (When patient clearly forgot to take their meds) I have rotated with different PCPs with minimal referral to ED as well. Just wanted to get some insight about everyone's thought process here for common conditions: 1)60 y/o, syncopal episode 3 days back, associated with some vomiting. Now having some vague " weakness since then and occasional blurry vision". H/o HTN CAD s”
“Had a pt come back(at a highly regardled teaching hospital) on the transport that the resident came with on assist control, rate 1”
It depends the charting system and the kind of IV pump. Do you have?
“Heard this recently. Like, okay that was all wrong but I’m following you. You’re currently taking one 325mg aspirin QD despite being recommended to only take one 81mg aspirin QD. This is because when you were selecting the aspirin to take, you saw that that there was also a 325mg dose right next to the 81mg doses. You, being the intelligent person that you are, thought to yourself that 325mg is more mg than 81mg and so it must be better. What does that doctor know anyway? submitted by  ”
“RANT/ 4yo patient new to me. CP, doesn't walk. Still in diapers. Markedly delayed/intellectually disabled (BTW, I wish they'd update the ICD-10s/IMOs because "mental retardation" is an outmoded term and it's still the one I have to use on the problem list). NOBODY at her prior practice had thought to order a PT referral. NOBODY at her prior practice had prescribed a wheelchair, walker, or stroller. NOBODY had done an OT referral. NOBODY had offered to prescribe diapers. I w”
“Just frustrated. I was referred to rheumatology because my CRP and ESR continue to elevate regardless of weight loss.... I say that because my doctors keep telling me my inflammation is because of my weight. Well, I'm down 40 pounds and the inflammation keeps on rising and WBCs are still high. Weight loss has been a LONG journey, it's taken 2 years to lose this much. Rheumatologist basically said he doesn't think I have lupus or arthritis (surprise: I don't think so either). I re”
“Link to original post in comments. I didn't respond to comments at the time but many of the comments mentioned following medical protocol in that my insurance would require PT/OT before an MRI. The second doctor ordered a hand MRI and it was approved immediately(I have really great insurance). The first doctor never suggested any treatment aside from more steroid injections and time. I even asked about a brace because he claimed I had tendinitis related to trigger finger. He told me he "”
“I had a patient come in with a GI bleed, reported tarry black stools hgb was a 54 g/L in emerg and they gave him 4 units of PRBCs. Turns out he had bleeding esophageal varices :0 I get him 4 days later up on medsurg and I get a critical in the morning that his hemoglobin dropped from 72 to 68. Not a big deal but I know I’m going to have to do a transfusion. I go to the patient as ask him if he’s having any new bleeding and he says “I did notice blood in my urine this morning it was red” so I’m t”
“Does anyone ever really need 4 point restraints, mitten restraints, a roll belt, and precedex to the maximum dose? submitted by /u/pulpwalt [link] [comments]”
“The hypothetical: You are treating a patient for (insert your specialty here) and they report that they've been experiencing SOB, arm/jaw pain, and nausea for the past three days. You take their vitals: heart rate and blood pressure are well within their normal range. They do not appear in any immediate distress. They have never been seen by a cardiologist. How urgently would you react? Would you call 911? Recommend they drive themselves to the ER that day? Recommend making an appointment wi”
“Cause I did an admit and she’s like you should order this CT abdomen test to rule out infection since she’s immunocompromised and has had diarrhea. She mentions urine studies to assess Aki too which I usually dont order for Aki And I feel like it’s basic and something I should have thought about beforehand I’m really afraid that my attending will think I’m below average. I’m on remediation and my PD is considering having me leave the program. They are judging me for every little thing. My questi”
“What are medicines you prescribe for patient satisfaction bc you have lost the will to live (sarcasm)? Case: 40M no hx of lung disease presents with URI symptoms x 3 days. Go over negative CXR, clear lung sounds, COVID + swab Pt asks for an inhaler prescription I explain why it is not clinically indicated He accepts the explanation without further fuss Soon after discharge we get multiple phone calls from family members harassing staff that he didn't get an inhaler 😑 the hills I am willing”
“Interestingly, there are no "standard" concentrations of vasopressors unless they are premixed like DOPamine. At one facility I worked at, epi was 2/250, while levo was 4/250. Add on top of that that some places do weight-based dosing for some meds and not others, and it's pretty easy to see how stuff got messed up.”
“my ER doesn’t let us use the guardrails on the pumps bc they usually don’t have the correct rates we use anyway, we do the math and reference against our protocol that has titration rates listed. i’m lucky and have my provider right next to me most of the time so i always double check with them too”
“You were this close 🤏🏻 to becoming RaDonda Vaught. No “oopsie” about it. Understand the weight and the consequences of your error, learn from it, and NEVER make it again.”
“Just trying to see something here- If you had a patient come up from endoscopy with a blood pressure of 209/98, not responding to meds- would you hold fluids NS @ 125ml or would you resume them because the doctor didn’t say you can hold them? submitted by /u/Apprehensive-Cap816 [link] [comments]”
“Calling all EM pharmacists I am looking for guidance! In short I was hired as a fresh new grad pharmacist in Canada, into an ED clinical pharmacist role at a ~ 50 bed academic hospital site (no trauma; that’s at our other site). No residency. I’m struggling to figure out how to actually add value because the ED already functions well without a pharmacist. Things I’ve found don’t really work in our setting: Resus: nurses draw/administer meds and there is resistance to pharmacy taking over this ro”
“Had a patient come in today that needs the rest of her maxillary teeth out. ideally we’d place some implants afterward. Shes 45 and takes enbril and methotrexate for RA. I do a lot of extractions but I’m wondering if this is one I should punt to the surgeon or not. What precautions would anybody take or risks you‘d be concerned with for an RA patient? submitted by /u/cbbutle [link] [comments]”
“Pt was being seen for pyelonephritis, I hung Rocephin before grabbing cultures. Crazy busy day and it just slipped my mind, very stupid mistake. Has anyone experienced adverse patient outcomes because of this? I understand if this happens often the Joint Commission is dissatisfied. Has this ever happened to any of you? What was the end result? submitted by /u/Deep_Stroker56 [link] [comments]”
“Case here: https://expertwitness.substack.com/p/delayed-pneumonia-treatment-septic tl:dr 45-year-old woman goes to urgent care with fever, chills, SOB. Temp 100.8, pulse 134, sat 92% on RA, no BP taken CXR shows left side pneumonia, azithromycin prescribed, patient discharged. Goes to the ED later that day feeling worse. She’s hypotensive, sat slowly declining. Gets 500mL of NS and Vanc/Zosyn given a few hours later. Lactate 4, WBCs 0.7 with 24% bands. Admitted to Hospitalist with pulm consult.”
“Link for those who need it: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001466 (link fixed) Wanted to discuss the new guidelines with the general medical community on here as I find these guidelines very interesting. In some ways, it is incredibly comprehensive, especially with guidance on follow up echos, dental health, etc which always seem to get thrown to the wayside. I also appreciate them trying to tackle valvular surgery in patients with CVA as this is a MAJOR holdup with patien”
“I feel like most of the time we’re asking if something is hyperk or VT, but what about cases where VT is caused by hyperk? Should we just look for a VERY wide QRS and if our suspicion is VT from hyperk should electrical cardioversion even be attempted prior to calcium and bicarb? Just curious on people’s thoughts here. I had an ECG question on Rosh that I’ve shared. submitted by /u/Weird-Accident-5928 [link] [comments]”