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

Relevant History:

• How elevated is the heart rate, and what is the patient’s baseline heart rate?
• What is the complete history and hospital course of this patient’s SCI?
• Were there any other injuries sustained during their SCI?
• What is the documented ASIA status in this patient?
• Are there any other vital sign changes?
• Has there been any trauma?
• What was the patient doing when the tachycardia was noticed?
• What have the patient’s most recent lab values been? Specifically hemoglobin, platelets, white blood cell count, electrolytes, creatinine, BUN.
• Is the patient experiencing any other symptoms, such as dyspnea, pain, vision or hearing changes, mental status changes, skin changes, bowel or bladder changes, bleeding, fever, chills, nausea, vomiting?
• Functional history and current functional status, including equipment usage?
• Past Medical and Surgical History?
• Medications?
• Allergies?

Relevant Physical Examination:

• Vital signs. Specifically trending vital signs over the past several days.
• Inspection
• Cardiopulmonary exam
• Integumentary exam
• Brief neurological and musculoskeletal exam

+ Challenge Question

• Why perform an integumentary and musculoskeletal exam?

+ Challenge Answer

• The integumentary exam will indicate if there is any skin breakdown, rashes, or cyanosis. The musculoskeletal exam serves to identify any edema, deformities/fractures, or sources of pain.

+ What is your differential diagnosis for the patient’s elevated heart rate?

• Pulmonary embolism, pain, sepsis, physiologic, urinary tract infection, pressure injury, autonomic dysreflexia, pneumonia, cardiac dysrhythmia, intracranial bleeding.

+ How would you proceed with this patient?

• An acutely and prolonged elevated heart rate requires further investigation; thus, I would proceed with a diagnostic workup for this problem. I would start with an EKG, CBC with differential, BMP, urinalysis, and D-dimer. I would consider a head CT, chest x-ray, or thyroid studies depending on these results.

+ The results of your decision are as follows:

• EKG: sinus tachycardia
• CBC: hemoglobin 12.4, white blood cell count 5.6, platelets 224,000
• BMP: within normal limits
• Urinalysis: 3 WBCs/hpf
• D-dimer: 600 ng/ml (elevated)

+ The patient develops shortness of breath and her blood pressure drops to 90/60 mmHg. What would be your next steps?

• The patient is hemodynamically unstable. I am concerned about pulmonary embolism, but the first priority is to stabilize the patient. I would start supportive care intravenous fluids and supplemental oxygen with continuous oxygen saturation monitoring and regular vital sign checks. I would consider starting vasopressors. I would call a rapid response as well at this point, given the patient’s hemodynamic instability.

+ Your actions result in the patient achieving hemodynamic stability. How would you now proceed?

• I would obtain a stat chest CT with pulmonary angiogram.

+ Your next steps result in the following:

• The chest CT returns positive for pulmonary embolism. The patient is hemodynamically stable.

+ What is your next step?

• I would like to initiate anticoagulation with heparin, but this patient’s concurrent subdural hematoma is likely at least a relative contraindication to anticoagulation. I would initiate a stat transfer to internal medicine or the ICU, with recommendations to obtain a stat head CT and place a stat consult to neurosurgery for their input regarding anticoagulation in the setting of a subdural hematoma.

+ Your actions result in the following:

• The patient is ultimately anticoagulated and presents to your inpatient rehabilitation unit 3 weeks later for ongoing functional recovery. Your screening doppler scans of the lower extremities reveal a large deep vein thrombosis (DVT) in the right lower extremity. The patient remains on anticoagulation.

+ How would you proceed?

• I would consult interventional radiology to consider placing an inferior vena cava filter (IVC filter). I want to avoid another pulmonary embolism. I would also discuss this option and its rationale with the patient to identify what her wishes would be. In addition, I would consult hematology for a hypercoagulability workup, as this patient manifests essentially an unprovoked DVT at this point in the setting of active anticoagulation.

+ “Doctor, am I ever going to walk again?”

• This is a great question, and I am glad you are invested in your recovery. Your neurologic testing (ASIA exam) shows what is called a C7 ASIA A injury. I am happy to discuss the details of that testing and what everything means for you in more understandable terms. Your injury occurred in the spinal cord in your neck, which means your body below that level will have difficulty performing its usual functions, like moving your legs, feeling your skin, and controlling your bowel and bladder. While no one can predict the future, unfortunately your type and level of injury do not typically lead to the ability to walk independently, though you may see some neurologic and functional recovery in some capacity. I want to reassure you that we will repeat your neurologic testing (ASIA exam) prior to your discharge from this facility, and we will plan to repeat the testing on an annual basis to monitor your neurologic recovery. We can always hope for more recovery beyond what is expected based on your test results. In the meantime, let’s hope for the best, but prepare you for the skills to take care of yourself with the highest level of independence that you can, so that, should you need those skills, you will have them. I want you to be as independent as possible, which is what your rehabilitation stay will facilitate, and which will likely include the goal of being independent at a wheelchair level. We will support you in every way that we can as you rehabilitate. Are there other questions you have for me, or is there perhaps anything else I can help to explain or clarify?