A 30s woman comes to the ED with a diagnosis of a DVT. She has had intermittent L leg swelling on and off for several months, and she went for an outpatient Doppler study this weekend morning. She was told to come to the ED immediately because she has a DVT. She has a radiology report and a CD with her. The report states that she has a thrombus in her CFV, SFV, and popliteal veins. There are no longer any CD drives in your hospital. The patient denies dyspnea, chest pain, or leg pain. She has no medical problems and she is not on OCPs. On exam, she has obvious, mild swelling of the L leg. What do you do?
Do you repeat the sonogram?
Do you send a hypercoagulable work-up from the ED?
Do you start treatment? Do you give enoxaparin, an NOAC, or warfarin?
Do you admit or discharge the patient?
Bounceback answer
The short answer is that the previous team did nothing wrong. As an ED doc, you will send many pyelo / UTI patients home. It is inevitable that some patients will bounce back, and occasionally some patients will bounce back sicker. This is true of virtually all infections that we see in the ED.
I tend to admit (1) patients that don’t look well, (2) nursing home patients, and (3) patients with documented resistant organisms. Criteria (1) is a combination of appearance, ability to walk, and ability to eat and drink. As far as I know, I have only had one patient bounce back in 20+ years, but I think the true number is likely higher.
I ALWAYS want to know if my patient bounces back. I want to know if I did something wrong so that I don’t make the same mistake again. I always tell the other team when a patient bounces back. If there was an obvious mistake, I tell them. In this case, the patient appeared well and wanted to go home. Imho, it was an appropriate discharge. I’m sure someone out there disagrees with the initial dispo plan.
The patient was readmitted and did perfectly fine.