Last week, I talked about lessons learned while on call, and I can’t help but continue the theme after a patient encounter I experienced recently. Some situations appear to occur without us having a second thought, while others are chock full o’ learnin’! I'm sure that each patient encounter is a chance for us to learn more about medicine and life in general, but if we focused that much attention on every situation, we would be mentally and emotionally overloaded and couldn't function. So… let’s talk about one particular encounter and what we can glean from this situation. We will call this, The case of the achy appendage.

First, a little backstory before we get to recent events. Some of the details have been altered for patient confidentiality, but the gist of things will remain consistent. About a year-and-a-half ago, I did a right ankle surgery on a 56-year-old female. During the first week post-op, the patient called complaining of pain in the contralateral calf, and I immediately sent her to the ER. The patient was diagnosed with a femoral vein deep venous thrombosis. She was discharged on an oral anticoagulant and, concerned that she wasn’t treated well at the ER, came in to my office the next day. Perhaps not surprisingly she was also complaining of chest pain, at which point I immediately sent her back to the ER where – you guessed it – she also had a pulmonary embolism. During the hospitalization, an inferior vena caval (IVC) filter was placed and she was started on apixaban. Happily, she healed from her ankle surgery without an issue, and she was lost to follow-up after about three months of initial postoperative care.

Fast-forward a year, when the patient recently came back in to the office. She now had a new complaint of achy, burning pain, and swelling in the leg with the prior DVT. She additionally noted patchy areas of brown discoloration on the medial aspect of the ankle, and chest pain at the upper right side of her chest. In the interval since we had seen each other, someone attempted to remove the IVC filter from an internal jugular vein approach, but was unsuccessful. The physical examination was pretty benign with left calf pain, very mild nonpitting edema, and diffuse hyperpigmentation at the medial malleolar area. A little concerningly, she attributed her left leg pain to the right ankle surgery I had performed.

Before we get to her diagnosis – at least what I thought it was – let’s consider the opportunities to learn by a case presented like this.

Let’s start with the medicolegal aspect. I was immediately on guard because of her implying the surgery I did on the right side actually caused the left-sided calf pain. I took a few extra minutes during our conversation to remind her that I recognized both the DVT and the PE, and both had been treated appropriately. In fact, this may have saved her life. I then discussed in detail what I thought of her diagnosis and the plan of care moving forward (more on that below). I then documented our discussion in a detailed fashion. What lessons can we learn from this?

Every patient deserves a clear picture of their situation and our role in it. Honesty and respect establish a legitimate relationship, and any normal patient will respond positively to that approach. Detailed documentation also helps from a medicolegal aspect. For example, in many states the date at which a problem or complication is documented begins the clock for the statute of limitations on a malpractice lawsuit. I also include in my notes complimentary comments my patients make of me. If a patient tells me, “I’m so happy with the results of my surgery,” I add that in the note. It’s not for hubris or narcissism that I do this. If a lawsuit were to occur, statements such as this would belie a plaintiff’s complaint. If I did such a good job and am such a good doctor, according to the patient, then a jury may be more sympathetic to my side of the story. Remember, a well-drafted chart note is a doctor’s best shield in the medicolegal world.

Our next lesson is the important role of diagnosis. In order to appropriately treat this patient, it is paramount to obtain a diagnosis. This is the fundamental pillar upon which modern medicine is based. Without a solid diagnosis effective treatment is impossible. Consider that the primacy of diagnosis is relatively recent in medical history, which has been aided significantly with new technology. In the past, doctors did not understand the pathogenesis of many diseases and essentially treated symptoms. The improvements in our understanding of disease plus technological advancements greatly increased the power of medicine to improve health and well-being.

However, we have seen a trend in recent decades away from diagnosis based on a complete history and physical, and toward ever-increasing numbers of advanced tests. Dr Abraham Verghese, an infectious disease specialist, nationally-known writer, and Stanford physician has, for many years now, spearheaded the Stanford Medicine 25 (stanfordmedicine25.stanford.edu). This is a resource to improve the patient-physician interaction and reduce what Verghese refers to as the iPatient. If you spend time in a teaching facility, you’ll be well aware of this. Residents spend most of their time on the computer placing orders for tests and medications based on the results of prior tests, while performing only a cursory history and physical examination.

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“Greater than 90% of diagnoses can be made by the history alone”

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I couldn’t agree with Dr Verghese more. Most of us are well aware of the statistic that greater than 90% of diagnoses can be made by the history alone. In fact, our case today demonstrates this very clearly. Never forget that each component of the patient encounter should reinforce and support the preceding one. The findings of the physical examination should confirm or refute the diagnosis or differential diagnosis already considered during the history. Imaging and laboratory data should again confirm or refute what was found in the history and physical. Imaging or labs alone should not be used to make the diagnosis.

Let’s now bring this back to our patient with the achy appendage. What’s your diagnosis? If you came up with postphlebitic syndrome as the cause of the patient’s leg pain, swelling, and discoloration (due to hemosiderin deposition), then you would agree with my summary. The history of prior DVT, severe in this case, plus the mild physical examination signs, screams postphlebitic syndrome. An incompetent venous system, damaged by the prior DVT, were no longer functioning adequately, and the patient, on her feet at work for long periods of time, experienced the resulting symptoms.

How about the right upper chest pain? This one is a little more difficult to figure out with certainty. The patient had described what sounded like an internal jugular vein approach to the IVC filter placement with the prior entry area being the location of her complaint. She also related an attempted but failed retrieval of the filter. It is clearly a logical conclusion that some complication of the IVC filter was the cause of her chest pain.

Treatment for this patient thus focused on the diagnoses. We applied a dynamic compression wrap to the left lower extremity, referred the patient to a venous specialist, and requested all prior charting to investigate the circumstances around the IVC filter placement and attempted removal. I plan to coordinate care with the other doctors involved to resolve her complaints.

The case of the achy appendage will likely have more episodes to follow. However, but with a logical thought process and continually reassessing the diagnosis, my patient has a good chance for improvement of her symptoms. Good luck with your next diagnostic challenge.