+ What are the key components of this patient’s history and physical examination?

Relevant History:

• What are the pain characteristics? What is the onset, context, location, duration, aggravating/alleviating factors, radiation, quality, severity?
• Was there trauma/injury?
• Has there been any swelling, spasticity, muscle tightness, skin changes, or numbness/tingling?
• Have there been any functional changes?
• Has this pain ever occurred before?
• Have there been any fevers or chills?
• Has there been any workup or imaging?
• Past medical and surgical history?
• Medications including DVT prophylaxis?

Relevant Physical Examination:

• Vital signs (note any fever, tachycardia to suggest pain or sepsis, hypotension to suggest sepsis, or hypoxia to suggest pulmonary embolism)
• Inspection (note any skin changes, atrophy, deformities, swelling, positioning abnormalities)
• Palpation of the affected leg (note any edema, point tenderness)
• Passive and active range of motion at the bilateral hips, knees, and ankles
• Manual muscle testing of the bilateral lower extremities
• Sensory testing (note any sensation changes or allodynia)
• The affected leg should be compared to the contralateral leg in all of the above testing

+ What is your differential diagnosis for her calf pain?

• Lower extremity DVT given unilateral pain and swelling, spasticity or muscle spasms given weakness on the affected side, neuropathic pain given impaired sensation on the affected side, cellulitis given unilateral pain and tenderness, fracture given unilateral pain and tenderness; other diagnoses to consider include lumbar radiculopathy, peripheral neuropathy, contusion, delayed onset muscle soreness, sprain, tendonitis, arthritis

+ What initial tests would you order?

• I would order venous doppler ultrasounds of the bilateral lower extremities to rule out DVT. I would also order a CBC to check for leukocytosis. If these tests came back negative then I would consider x-ray imaging of the left lower extremity.

+ How would you manage this condition?

• This is a difficult case because the patient has a new proximal DVT, which could progress to a life-threatening pulmonary embolism if left untreated. On the other hand, she has had a recent subdural hematoma which has not resolved on CT head, and anticoagulation could worsen this bleed which would likely worsen morbidity or mortality if it was to occur. My first step would be to place the patient on bedrest and to inform her of her condition. I would then reach out to her neurosurgical team for clearance to start anticoagulation. If clearance is obtained, I would start full dose therapeutic anticoagulation, such as IV heparin, weight-based enoxaparin, or oral agents. If clearance is not obtained, I would place an IVC filter to stop venous thromboemboli from traveling to the lungs. If unable to reach the neurosurgical team, the decision to start anticoagulation or place an IVC filter would require careful weighing of the bleeding risk and discussion with the patient and/or POA.

+ Challenge Question

• The neurosurgical team clears the patient for anticoagulation but hangs up before you decide on an agent. What are the practical pros and cons of IV heparin vs an oral anticoagulant such as apixaban?

+ Challenge Answer

• IV heparin is more difficult to administer, requiring IV access and management of IV tubing as well as frequent blood draws to check levels, compared to oral agents which are relatively easy to administer. The benefit of IV heparin is that it can be discontinued quickly if the patient develops a new bleed or any concerning neurologic findings during administration, while oral agents are much more difficult to reverse.

+ What steps would you take to address this problem?

• I would begin by reviewing the actual percentages of patients with venous thromboemboli from this hospital compared to other hospitals in order to verify that there was a true discrepancy between this hospital and others. I would then review individual patient charts to see if something had been missed on acute care or in the transition process, paying close attention to DVT prophylaxis administration both on acute care and at inpatient rehabilitation. Perhaps the acute care hospital had not been giving DVT chemoprophylaxis, or perhaps there was a missing piece in my inpatient rehabilitation unit’s admitting process that caused us to forget to give chemoprophylaxis while at rehab. It is also possible that there is a different underlying reason including patient population or other comorbidities that could contribute to the higher rate of DVTs from this hospital. Once the issue is identified, I would discuss this with my department chair and likely reach out to representatives at the acute care hospital including department chairs, unit directors, or patient safety officers in order to fix the issue.

+ How would you respond?

• “Thank you for calling me to discuss this issue. I would be happy to discuss it with you but first I need your daughter’s permission to discuss this with you.”

• Wait for the examiner’s response. If no permission is granted, stop the conversation. If permission is granted, then continue.

• “I understand that it is extremely frustrating to learn about another diagnosis and setback after everything that your daughter has been through. We were looking forward to starting her rehabilitation program with her and are now met with this new setback, which I am sure is very difficult and frustrating for you and for your daughter. I recommend that you reach out to the patient’s last doctor to discuss your concerns and get more clarification. DVTs and PEs are unfortunately a common complication for people who are hospitalized and less mobile than they are used to being. It’s also important to realize that patients can have DVTs or PEs without any signs or symptoms. The good news is that we were able to identify this issue before it progressed to a life-threatening condition. She is getting the appropriate treatment and we will be able to start our rehabilitation program without a significant delay. She is clinically stable and doing quite well. Do you have any other questions about her care plan?”

• Note: The question of whether or not to sue another healthcare provider or hospital is always difficult. As with any case, you should make sure that you have a patient’s permission to speak with a family member or acquaintance before starting your conversation. In cases where you are asked about litigation, the most important thing to do in the beginning is to show empathy and understanding of the situation. You want to diffuse the situation as much as possible by showing that you understand the frustration that they are experiencing, and this will build rapport with the patient or family member who is calling you. After you have expressed your understanding of the situation, it is best to AVOID making any judgements on another provider’s care. You should always defer to the other provider and recommend that they schedule an appointment with the other provider to discuss the case and get more information. You should then offer assurance and your insight on rehabilitation progress or potential if appropriate.