Sometimes, when you see a patient, you get the feeling that the patient “must have something”.
When I see a patient as a bounce-back, I always check to see who saw the patient last. Was it a doctor I trust, or was it someone I don’t trust? The patient was seen by an attending I trust.
Both Lulu and I felt that this patient fell into the “must have something” category. What could have been missed by the previous team? Her belly was completely non-tender and she had no GI, GU, or Gyn symptoms.
We came up with the same plan independently (I’m a fan of writing it on a piece of a paper followed by a simultaneous reveal). We both chose LE venous Doppler. There was zero pain or swelling in her legs, but it was the most likely thing to have been missed.
Her DVT study showed bilateral common femoral / superficial femoral DVTs. She was started on AC. A CT scan was negative for PE (shocking given her tachycardia) but it confirmed the suspicion of an IVC clot.
The treatment of DVT is typically AC and home, but not all DVTs are equal. A “central” DVT (usually defined as DVT of iliac / IVC) requires additional intervention – typically a vascular procedure which may include thrombolysis, thrombectomy, and/or stenting. The patient was admitted to the hospital. Vascular intervention is aimed at improving function (patients don’t do well with a chronic bad leg).
It is extremely unusual for a young person to have such extensive DVTs despite the use of OCPs. Thus far, her hematology tests were all normal.
I ALWAYS tell the other team of their miss. I would always want to know myself so I don’t make the same mistake again. The previous team considered DVT, but they did not pursue the study because her exam was so normal. It was also a chaotic day (I was also working) where patients were seen in the halls. Overcrowding leads to errors, both big and small. When I saw the patient, it was a quieter day and we saw her in Gyn. We had more time to think. Who is responsible for these misses – the clinician, the hospital/admin, or public policy?