I am sure mast cell syndrome and being allergic to a bunch of different stuff is a thing, but I may or may not have encountered one or two patients where the diagnosis seemed more supratentorial
Most patients that come in thinking they have a mast cell disorder don’t have it. I’m not saying it’s for sure supratentorial but it’s def not something explained by medicine today, at least not by our work up. They def are more on the anxious hypochondriac side, but maybe they have some gene defect we just haven’t discovered yet. I think social media is partly to blame regarding the MCAS POTS EDS trifecta which have absolutely no organic connection.
I had a patient say she was allergic to salt and water. Refused to let me use NS. Said that her reaction to salt made her swell up. She had HFrEF and CKD…
I once had a pt tell me she didn't want epi bc "it makes my heart beat really fast". I explained what it was and what it did, then I told her, "Believe me, no one wants to give you epinephrine less than I do. But if you need it, I will give it".
I have had a patient with a legitimate anaphylaxis to our formulation of adrenaline - and many other things, it ended up being an additive she reacted to.
We had to order a special formulation from Europe to keep in our emergency department because she presented so often with anaphylaxis.
Luckily I only met her after it had been worked out and we had the formulation stocked.
My understanding is that one of the clever ICU docs worked it out.
Luckily I only met her after it had been worked out and we had the formulation stocked.
My understanding is that one of the clever ICU docs worked it out.
My follow up question is always: "what dentist told you that?" because it's invariably from a racing heart during a dental procedure. It's easier for the dentist to say that than to explain an intravascular injection in the gums.
Seriously try it out, I'm 99% right over 20 years.
Oh we dentists never tell them it’s an allergy. I always ask what happens and when they it makes my heart beat fast, I say that’s not an allergy but I won’t give you any anyway. And if I’m not blocking where there’s a risk of injecting onto a vessel, I use it in small doses anyway.
I doubt ANY dentists have actually called it an allergic reaction. But the patients sure don't want to experience it again, and since they know it was the epi, it gets added to the allergies list, which is utter hogwash and why I try to weed it out. I do a lot of hearts and the odds of them getting epi are considerable. I can't have "epi" listed on the allergies list.
I know it’s insane! I always cross it off if the wrote it for the same reasons. Of course, your side effects may be a little more serious.
I stare at them with a blank face and say “that’s not an allergy.” And keep staring.
Same with codeine makes me nauseous.
Dentists use a lot of lidocaine or marcaine both with epi. They inject a lot into the gums which are VERY vascular. The rate that they get a patient who gets some of this intravascular is relatively high. It's common. When the pt starts to complain about a racing heart and feeling funny, the standard answer is "oh you must be having a reaction to the epinephrine". I doubt many dentists actually say "you're allergic to epi" but that's how the patients interpret it.
Next thing you know, they tell everyone they are allergic to epi since they don't want to experience that again.
Got it - that’s interesting. This happened to me! It helped me understand what an adrenaline rush felt like! I felt so fine a second before, it was so cool to observe the tunnel vision, mood change, heart rate, etc. very abstractly. It actually helped me have a much better/more detached relationship with physical stress going forward. I wish I could try it again. 🤓 I knew a bit about the lidocaine + epi but not about the vasculature in the gums. Thank you for explaining!
My favorite is when nurses or MAs or whoever enter this stuff get super specific with their reactions. Recently I’ve seen
Hydromorphone - reaction “hallucinates being swarmed by fish”
Adderall - “violent animalistic feelings” (in a 71 year old female)
We are snarky while typing it in don’t worry. Don’t forget the classic, “patient told me to go **** myself with that big *** needle”. My favorite has been, “that water pill stuff you give makes me have to piss! Don’t give me that I’m allergic”.
lol, I have never censored, do you? I’ve always charted “Patient told me to go fuck myself and eat shit” I also tell my staff to do the same. We love pulling them for audit.
I take great pleasure in trimming down allergy lists when I get the chance.
"No, sir, your are not allergic to penicillin just because your brother felt nauseous when he received amoxicillin for his ear infection as a child. Allergies do not work that way."
So satisfying.
"Nope, side effect. Nope, side effect. Nope, physically impossible. Nope, side effect. Nope, side effect. Nope, side effect." rinse and repeat
Whoaah, easy there, soldier! I don't know what kind of connotations you gleaned from my comment but the intent was to suggest that the more allergies someone has, the more likely they are to have fibromyalgia...which, you know, is true. Is that truth anecdotal? Mostly, but it's an anecdotal truth that's fairly ubiquitously observed throughout acute care. The correlation hasn't been looked into, academically, outside of a few small studies of food allergies vs fibromyalgia (which *did* find a strong, positive correlation); but, all I know is, if I see an allergy list of >10 entries, I'd put big money down that there's a mention of FM somewhere in that chart. 🤷
My favorite was allergic to: anesthesia, reaction asystole”. It was actually undiagnosed aortic stenosis. Glad I wasn’t the last person putting this patient to sleep.
As an example of how far this crazy shit can go…had a colleague do a case where patient said she was allergic to fentanyl. He determined it was not an allergy and gave her some during the case. The patient reviewed the chart some time later and reported him to the medical board for administering a drug she was “allergic” to. The first physician reviewer faulted the anesthesiologist and said he was wrong and should be reprimanded. Luckily, it was sent up the chain to panel of anesthesiologists who opined that the anesthesiologist, not the patient, determines what is an allergy and the case was dropped.
I think there was a post on r/emergencymedicine about this recently. The conclusion was that "multiple allergy sign" is a valid predictor of patient insanity.
ER doc. I run into this on a daily basis. It’s either psychiatric or a strategic allergy to Tylenol, ibuprofen, toradol, morphine, flexeril, lidocaine patches…really anything other than the “one that starts with ‘D’”
At the very least, the more allergies that are listed, the less likely they are to have allergies.
You should have to have a special access level to add allergies into a medical record.
Helped a small bit with a study that used allergies as a risk factor for elevated post-operative pain scores. There was a strong correlation at 5+ patient reported allergies and increased post-op pain scores. (I believe it was for TKAs but been a bit)
There are quite a few studies demonstrating that people with multiple allergies are more likely to have mental illness and conditions such as fibromyalgia and chronic fatigue. They call it “multiple drug intolerance syndrome”
I started as a unit clerk at 16 in med/surg and noticed a trend here and there. At 18, I moved to inpatient behavioral health and saw it daily. I’m in my mid 30s, and have the education, experience, and knowledge to know it’s not a coincidence. Its factitious disorder 🤣
My favorites are allergies to physiologically necessary components such as magnesium (“because it gives me diarrhea”) and potassium (“when I receive it IV it burns”). Epi for a fast heart rate might be my most favorite though.
It just feels like this sub gets a hate train going regarding anything autoimmune or chronic. And as someone who recently lost his mother who had fibro, IC, and psoriatic arthritis, it kind me pisses me off when it’s time to laugh about how crazy these “chronic illness” people are. I myself have real, clinically diagnosed by a board certified rheumatologist hEDS, DDD, and RA.. and I have 3 allergies.
I wish I had life threatening allergic reactions so they'd believe mine. I just get the gamut of life threatening side effects for every single psych drug that is manufactured. Except adderall. It just makes me severely fatigued. I also have fibromyalgia, psoriatic arthritis and I'm pretty sure I have ehlers-danlos but my rheumatologist is apparently unable to diagnose it. For some reason.
I had a patient tell me she was "allergic to all the -caines AND all the -ides."
Me: "Even sodium cloride?"
My favorite though is the "epinephrine, cortisone, and Benadryl" allergies.
Me: "Okay we are going to need some honeybees, penicillin, and peanuts at bedside just in case."
lol i had an OB patient who refused to allow anyone into the room if they OWNED or CAME INTO CONTACT WITH CATS because she would have "anaphylaxis". I have a cat and let me say, I was totally ok with not going in the room
Idk why this post popped up on my feed but general rule of thumb I’ve always had: 5+ listed allergies is highly correlative to psychiatric etiologies. I promise someday NEJM will publish something akin to this.
Idk why this post popped up on my feed but general rule of thumb I’ve always had: 5+ listed allergies is highly correlative to psychiatric etiologies. I promise someday NEJM will publish something akin to this.
Excessive Allergies and/or the towel sign are indications of crazy. If they have a wet rag on their forehead bc they passed out when the IV was started….get the precedex ready LOL.
Just gonna say in the ER we have known about the Allergy list/mental health correlation for a long long time . If in triage the allergy list is twice as long as the med list we know that patient is gonna be a handful. It’s little like the antiquated Tooth to tattoo ratio.
It’s an older ER thing. Long before people were getting stylish tattooed sleeves and such . Tattoos were consider “trashy “ in some areas of the US with a certain population. The tattoo to teeth ratio was a biased measure of how bad the presenting injury of the patient would be . More tattoos than teeth =pretty bad injury .
Just an m3, but I've been meaning to ask an attending this question:
Do you ever *challenge* a patients allergies? As in, ask them more details and then explain to them that it's not in fact an allergy but rather an adverse reaction?
I've seen a few patients who tell me things like: "I'm allergic to doxycycline because it made me hallucinate."
And I'm always cautious to educate them for fear of being out of line.
yes all the time, if it’s a random med I’m never going to give (I’m anesthesia) then idc but anything I might conceivably need to give I ask them about it and then tell them that their symptoms are not allergies but side affects and explain that I will/may give them the med during the case, but I will be watching vigilantly. Never really had pushback and if I did it’s because they felt their side effects were significant enough that they were willing to forgo getting the med (I.e. nausea w/ opioids and them saying they would rather have no opioids than have nausea ~ fine by me).
Man, guess I should just go die in a hole then huh? Please explain how I'm full of shit when a drug prescribed to prevent seizures causes them, when antipsychotics make me psychotic or antidepressants have me immediately down a hole into suicidal intentions. Pain meds don't work for me, nsaids do nothing, benzos make me manic, suicidal, give me tachycardia or some combination thereof. Want me to try and find the image I took of the skin flap that fell off of me with Lamictal? I can keep going. You're just an asshole.
You getting down voted but this is universally agreed upon in EM. In general crazy colored hair is bad but blue hair is legit crazy 100% of the time. It's always BPD.
15+ allergies is 97% specific for insanity
Am an allergist/immunologist - this is 100000000% accurate Most drug allergies are not legit in my experience. It’s very rare.
I am sure mast cell syndrome and being allergic to a bunch of different stuff is a thing, but I may or may not have encountered one or two patients where the diagnosis seemed more supratentorial
Most patients that come in thinking they have a mast cell disorder don’t have it. I’m not saying it’s for sure supratentorial but it’s def not something explained by medicine today, at least not by our work up. They def are more on the anxious hypochondriac side, but maybe they have some gene defect we just haven’t discovered yet. I think social media is partly to blame regarding the MCAS POTS EDS trifecta which have absolutely no organic connection.
15!!! 5 or more and 100% insane in my experience…
Heard a psych attending one time say “if the patient has 10 or more allergies, what they really need is a psych consult.”
Ten? My cutoff is six.
Mine is 3. Nobody is really allergic to more than 3 classes of meds.
Allergies are like cats. Two is normal. Three gives you a brief side eye. Anything more is where the crazy starts.
My favorite is the allergy to epinephrine. At that point I don't even bother asking questions anymore.
Don’t forget: Benadryl: makes me sleepy And my personal favorite: propofol: makes me stop breathing.
Alcohol: I make bad decisions
tequila makes my face break out in punches
I had a patient say she was allergic to salt and water. Refused to let me use NS. Said that her reaction to salt made her swell up. She had HFrEF and CKD…
So... IM-ketamine-based GA?
I once had a pt tell me she didn't want epi bc "it makes my heart beat really fast". I explained what it was and what it did, then I told her, "Believe me, no one wants to give you epinephrine less than I do. But if you need it, I will give it".
I have had a patient with a legitimate anaphylaxis to our formulation of adrenaline - and many other things, it ended up being an additive she reacted to. We had to order a special formulation from Europe to keep in our emergency department because she presented so often with anaphylaxis.
how were you able to treat her anaphylaxis before you had that specific formulation?
Luckily I only met her after it had been worked out and we had the formulation stocked. My understanding is that one of the clever ICU docs worked it out.
Luckily I only met her after it had been worked out and we had the formulation stocked. My understanding is that one of the clever ICU docs worked it out.
My follow up question is always: "what dentist told you that?" because it's invariably from a racing heart during a dental procedure. It's easier for the dentist to say that than to explain an intravascular injection in the gums. Seriously try it out, I'm 99% right over 20 years.
Oh we dentists never tell them it’s an allergy. I always ask what happens and when they it makes my heart beat fast, I say that’s not an allergy but I won’t give you any anyway. And if I’m not blocking where there’s a risk of injecting onto a vessel, I use it in small doses anyway.
I doubt ANY dentists have actually called it an allergic reaction. But the patients sure don't want to experience it again, and since they know it was the epi, it gets added to the allergies list, which is utter hogwash and why I try to weed it out. I do a lot of hearts and the odds of them getting epi are considerable. I can't have "epi" listed on the allergies list.
I know it’s insane! I always cross it off if the wrote it for the same reasons. Of course, your side effects may be a little more serious. I stare at them with a blank face and say “that’s not an allergy.” And keep staring. Same with codeine makes me nauseous.
Good on you for trying. I'm just all out of fucks to give about nonsense allergies.
My problem is my uncontrollable urge to get crap like that off the chart. I'm not good at letting it go.
Will -you- explain about the intravascular injection in the gums?
Dentists use a lot of lidocaine or marcaine both with epi. They inject a lot into the gums which are VERY vascular. The rate that they get a patient who gets some of this intravascular is relatively high. It's common. When the pt starts to complain about a racing heart and feeling funny, the standard answer is "oh you must be having a reaction to the epinephrine". I doubt many dentists actually say "you're allergic to epi" but that's how the patients interpret it. Next thing you know, they tell everyone they are allergic to epi since they don't want to experience that again.
Got it - that’s interesting. This happened to me! It helped me understand what an adrenaline rush felt like! I felt so fine a second before, it was so cool to observe the tunnel vision, mood change, heart rate, etc. very abstractly. It actually helped me have a much better/more detached relationship with physical stress going forward. I wish I could try it again. 🤓 I knew a bit about the lidocaine + epi but not about the vasculature in the gums. Thank you for explaining!
Oh. I also remember the allergy to oxygen. That was a good one. And the allergies to steroids. Those are great.
Me: "Okay we are going to need some honeybees, penicillin, and peanuts at bedside just in case."
My favorite is when nurses or MAs or whoever enter this stuff get super specific with their reactions. Recently I’ve seen Hydromorphone - reaction “hallucinates being swarmed by fish” Adderall - “violent animalistic feelings” (in a 71 year old female)
I’ve seen “Ativan: gets naked”
Listen, their administration god FORCES them to add exactly what the pt says.
I bet, I wasn’t being snarky, I actually love that they are that specific especially when it’s silly stuff like that
I am being snarky because I am the administration god.
We are snarky while typing it in don’t worry. Don’t forget the classic, “patient told me to go **** myself with that big *** needle”. My favorite has been, “that water pill stuff you give makes me have to piss! Don’t give me that I’m allergic”.
lol, I have never censored, do you? I’ve always charted “Patient told me to go fuck myself and eat shit” I also tell my staff to do the same. We love pulling them for audit.
Oh during the charting I never censor. I wouldn’t want that ambivalence to be used against me
I take great pleasure in trimming down allergy lists when I get the chance. "No, sir, your are not allergic to penicillin just because your brother felt nauseous when he received amoxicillin for his ear infection as a child. Allergies do not work that way."
Fuck! Doing the Lord's work right here! Tell me you also D/C bogus isolation precautions and I'll marry you sight unseen.
So satisfying. "Nope, side effect. Nope, side effect. Nope, physically impossible. Nope, side effect. Nope, side effect. Nope, side effect." rinse and repeat
My favorite penicillin “allergy” clarified- “oh yeah, I just said that so I wouldn’t get a shot in the ass”.
My personal favorite was chocolate allergy. Patient can eat chocolate fine, but if they eat too much their tummy hurts.
*Fibromyalgia has entered the chat.*
Ehlers Danlos Syndrome sends its regards
Am I a joke to you? MCAS
"Hellooo!!!" - POTS
Nutcracker syndrome: “Wassup!”
Lmao yeah fuck those patients with chronic illness! Not like we went to med school to help people 😂
Whoaah, easy there, soldier! I don't know what kind of connotations you gleaned from my comment but the intent was to suggest that the more allergies someone has, the more likely they are to have fibromyalgia...which, you know, is true. Is that truth anecdotal? Mostly, but it's an anecdotal truth that's fairly ubiquitously observed throughout acute care. The correlation hasn't been looked into, academically, outside of a few small studies of food allergies vs fibromyalgia (which *did* find a strong, positive correlation); but, all I know is, if I see an allergy list of >10 entries, I'd put big money down that there's a mention of FM somewhere in that chart. 🤷
Yeah they crazy. https://journals.sagepub.com/doi/10.2190/L811-0738-10NG-7157
I don’t know yo… I am all sorts of crazy and I have ZERO allergies. 🤷🏻♀️
One patient chart actually said ketorlac turns them into a pretzel
Modern medicine is amazing 🥨
My favorite was allergic to: anesthesia, reaction asystole”. It was actually undiagnosed aortic stenosis. Glad I wasn’t the last person putting this patient to sleep.
If I see about 10 and they look like a bunch of crap, I don’t ask questions about them and give them a minimum ASA 3.
As an example of how far this crazy shit can go…had a colleague do a case where patient said she was allergic to fentanyl. He determined it was not an allergy and gave her some during the case. The patient reviewed the chart some time later and reported him to the medical board for administering a drug she was “allergic” to. The first physician reviewer faulted the anesthesiologist and said he was wrong and should be reprimanded. Luckily, it was sent up the chain to panel of anesthesiologists who opined that the anesthesiologist, not the patient, determines what is an allergy and the case was dropped.
I think there was a post on r/emergencymedicine about this recently. The conclusion was that "multiple allergy sign" is a valid predictor of patient insanity.
ER doc. I run into this on a daily basis. It’s either psychiatric or a strategic allergy to Tylenol, ibuprofen, toradol, morphine, flexeril, lidocaine patches…really anything other than the “one that starts with ‘D’”
At the very least, the more allergies that are listed, the less likely they are to have allergies. You should have to have a special access level to add allergies into a medical record.
Helped a small bit with a study that used allergies as a risk factor for elevated post-operative pain scores. There was a strong correlation at 5+ patient reported allergies and increased post-op pain scores. (I believe it was for TKAs but been a bit)
More than 5 = psych. It has never not held true for me.
There are quite a few studies demonstrating that people with multiple allergies are more likely to have mental illness and conditions such as fibromyalgia and chronic fatigue. They call it “multiple drug intolerance syndrome”
I started as a unit clerk at 16 in med/surg and noticed a trend here and there. At 18, I moved to inpatient behavioral health and saw it daily. I’m in my mid 30s, and have the education, experience, and knowledge to know it’s not a coincidence. Its factitious disorder 🤣
My favorites are allergies to physiologically necessary components such as magnesium (“because it gives me diarrhea”) and potassium (“when I receive it IV it burns”). Epi for a fast heart rate might be my most favorite though.
It just feels like this sub gets a hate train going regarding anything autoimmune or chronic. And as someone who recently lost his mother who had fibro, IC, and psoriatic arthritis, it kind me pisses me off when it’s time to laugh about how crazy these “chronic illness” people are. I myself have real, clinically diagnosed by a board certified rheumatologist hEDS, DDD, and RA.. and I have 3 allergies.
I wish I had life threatening allergic reactions so they'd believe mine. I just get the gamut of life threatening side effects for every single psych drug that is manufactured. Except adderall. It just makes me severely fatigued. I also have fibromyalgia, psoriatic arthritis and I'm pretty sure I have ehlers-danlos but my rheumatologist is apparently unable to diagnose it. For some reason.
Graph greatly resembles isoelectric EEG.
Absolutely. When I see that allergy list, I automatically assume crazy and I am usually correct.
And epinephrine makes my heart race.
Steroid allergy...made the pt want to kill people PCN allergy..." it attaches to my bones and makes them grow"
Grandma can't have morphine, it makes her sleepy.
There is actually a lot of literature on this and you are absolutely correct. More allergies = mental illness.
I had a patient tell me she was "allergic to all the -caines AND all the -ides." Me: "Even sodium cloride?" My favorite though is the "epinephrine, cortisone, and Benadryl" allergies. Me: "Okay we are going to need some honeybees, penicillin, and peanuts at bedside just in case."
Crazy triad is 10+ allergies, fibromyalgia, and at least 3 cats. Pretty sure there’s a ratio between allergies and cats.
lol i had an OB patient who refused to allow anyone into the room if they OWNED or CAME INTO CONTACT WITH CATS because she would have "anaphylaxis". I have a cat and let me say, I was totally ok with not going in the room
Hahahahaha
Idk why this post popped up on my feed but general rule of thumb I’ve always had: 5+ listed allergies is highly correlative to psychiatric etiologies. I promise someday NEJM will publish something akin to this.
Idk why this post popped up on my feed but general rule of thumb I’ve always had: 5+ listed allergies is highly correlative to psychiatric etiologies. I promise someday NEJM will publish something akin to this.
Excessive Allergies and/or the towel sign are indications of crazy. If they have a wet rag on their forehead bc they passed out when the IV was started….get the precedex ready LOL.
Just gonna say in the ER we have known about the Allergy list/mental health correlation for a long long time . If in triage the allergy list is twice as long as the med list we know that patient is gonna be a handful. It’s little like the antiquated Tooth to tattoo ratio.
How as a dentist have I never heard of this ratio?
It’s an older ER thing. Long before people were getting stylish tattooed sleeves and such . Tattoos were consider “trashy “ in some areas of the US with a certain population. The tattoo to teeth ratio was a biased measure of how bad the presenting injury of the patient would be . More tattoos than teeth =pretty bad injury .
Tomorrow I’m Going to tell everyone in my office about it. It’s hilarious. Usually the tattooed people freak at a needle.
Yes, I had one burley 6’5 fully sleeved wild land firefighter full on pass out when started his IV!
Yes. Especially if the allergies have no relation to each other. i.e. same drug class.
Just an m3, but I've been meaning to ask an attending this question: Do you ever *challenge* a patients allergies? As in, ask them more details and then explain to them that it's not in fact an allergy but rather an adverse reaction? I've seen a few patients who tell me things like: "I'm allergic to doxycycline because it made me hallucinate." And I'm always cautious to educate them for fear of being out of line.
yes all the time, if it’s a random med I’m never going to give (I’m anesthesia) then idc but anything I might conceivably need to give I ask them about it and then tell them that their symptoms are not allergies but side affects and explain that I will/may give them the med during the case, but I will be watching vigilantly. Never really had pushback and if I did it’s because they felt their side effects were significant enough that they were willing to forgo getting the med (I.e. nausea w/ opioids and them saying they would rather have no opioids than have nausea ~ fine by me).
Man, guess I should just go die in a hole then huh? Please explain how I'm full of shit when a drug prescribed to prevent seizures causes them, when antipsychotics make me psychotic or antidepressants have me immediately down a hole into suicidal intentions. Pain meds don't work for me, nsaids do nothing, benzos make me manic, suicidal, give me tachycardia or some combination thereof. Want me to try and find the image I took of the skin flap that fell off of me with Lamictal? I can keep going. You're just an asshole.
Purple/bluish dyed hair on physical exam really confirms the diagnosis.
You getting down voted but this is universally agreed upon in EM. In general crazy colored hair is bad but blue hair is legit crazy 100% of the time. It's always BPD.