It was the usual busy evening in the ED. I had just finished intubating a 63-year-old woman who was fine until a few hours ago, when she suffered a confusional episode and collapsed. I went to look for the post-intubation CXR, and as I stepped out of the room, I encountered the nurse from the adjacent urgent care/fast track waiting for me…
“Doctor, I know you’re busy”, she said, following me towards my work cubicle, “but the PA asked if you would see the patient in the back room”.
“What’s the problem?”, I ask, half listening as I scroll the monitor for the CXR on the intubated patient.
“This is the third ER visit for this woman in a week. Her sinus problems aren’t getting better,” the nurse explains. “The PA says she is worried about her”.
“Where is this post-intubation X-ray?”, I ask aloud to no-one in particular when I can’t bring it up on screen. I felt a bit harried, wanting to get this critical case up to ICU. I returned my attention to the urgent care nurse, who patiently returned my gaze. “What is this urgent care story, again?”, I ask.
“Here is the chart”, she says helpfully, offering me the clipboard.
Sigh. “Alright, I’ve got a moment”. I hustled back to urgent care. My very wonderful PA was nowhere to be found—probably suturing or doing a pelvic exam. The woman in the back room is middle aged, well-dressed and pleasant, and, fully dressed, looking like she is ready to leave.
“My face has felt swollen all week”, she says. “I saw my family doctor, who said it was probably allergies. When I didn’t get better, I came here and saw this nice doctor” — my PA, it sounds like—“but the antibiotics for my sinus problems didn’t make things better. My head just feels more and more swollen. I don’t understand why I am not better”.
I felt myself rapidly losing interest in this case, as the sinusitis woman did not appear ill. After a brief exam, I reassured her and went back to look for my CXR on the intubated patient. Up on the viewer was the chest X-ray, by chance, from the woman I had just examined (Right). I did a double-take, and scurried back to the room to check something else on her physical exam. After conferring with the PA and updating the patient, we sent her for some additional testing.
What did the CXR show? What exam finding was I looking for? What additional imaging was ordered? See next page for answers.
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Infantry soldiers have always said that the mortar shell that kills you is the one you never hear. This one I heard just in time. The CXR showed what I did not expect to see—a dialysis catheter. It is very easy to skim over the history details of a patient who does not appear sick. In fact, we do it all the time out of sheer necessity. I have learned the hard way to take even the briefest look at the nurse’s triage note to review the patient’s allergies, PMH and other details.
But it is the catheter itself that is the critical clue. On re-examination, this patient had remarkable JVD for someone in the upright sitting position—but I needed to get her back in a hospital gown to best see this finding. Sometimes a focused physical exam is a jackpot. On more careful examination, her face did seem slightly swollen by comparison to other soft tissue regions. No Virginia, she’s not just chubby. That’s edema.
Needless to say, we ordered a CT scan of the chest and neck—with IV contrast. In addition to the dialysis catheter, the superior vena cava also contains clot (see arrow), with only a small region of bright-white contrast flowing around. Not a complete thrombosis, but well on the way. After that, it was IV heparin, a phone call to the admitting nephrologist, and admission. Two days later she spiked a fever, and had further problems due to her septic thrombophlebitis (ouch).
Now go to the blackboard and write fifty times: “I will always check the triage history… I will always do a good problem-focused physical examination… I will try not to rush through a patient evaluation even if I am busy with other ER crises” Well done.
John Dallara, MD, practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course. www.emprepcourse.com