The sixth sense of an experienced clinician

I just didn’t like the looks of him.

It was the way he was breathing. I counted for a full minute: 24 breaths. (The ER would later document 40.) No accessory muscle use. Not even much coughing. He didn’t look overly anxious or uncomfortable, though he said he couldn’t breathe. No fever. No wheezing or other abnormal lung sounds on exam. No leg swelling or tenderness. Pulse ox 95% on room air (97% in the ER.) Not terrible for a non-smoker in his 60s. Not much to go on.

I was afraid he had a blood clot in his lungs. Pulmonary embolism (PE, for short.) Life-threatening if not caught. Fever, cough, chest pain, anxiety, and leg pain (clots in the leg can break off and go to the lungs) would have been suggestive signs. Then again, their absence didn’t rule it out by any means.

Here’s the kicker: He was already on coumadin, a blood thinner, and his INR was 2.9 the week before. He was therapeutically anticoagulated. Blood thinners are supposed to prevent blood clots. He couldn’t have a blood clot in his lungs if he was already on blood thinners, could he? What was going on?

Pneumonia? Possibly, but with no cough, fever, chest pain, or abnormal lung exam, it seemed less likely. Asthma? Even less likely with a normal exam.

I just didn’t like the looks of him.

So I called the ER and told them I was sending him over.

“Already on coumadin?” asked the nurse.

“Yep.”

“Therapeutic INR?”

“That’s right.”

“Hmph. Probably not a PE. But send him over; we’ll take care of him.”

Later that afternoon, the patient called me.

“I just wanted to say thank you,” he began.

He had been admitted to the ICU with numerous blood clots in both lungs. The only other thing they could find was a little non-occlusive deep vein thrombosis in one of his popliteal veins; the kind that don’t typically break off and to to the lungs (especially when already on blood thinners.) The hematologist was stumped.

But he was alive. Which he probably would not have been if he had continued sitting at home, hoping to feel better, as he had told me he was his original plan.

That was a save. Based primarily on that sixth sense of the experienced clinician: I just didn’t like the looks of him.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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