The more we see ,less we understand and more are we humbled

2.  The more we see ,less we understand and
more are we humbled
 I am speaking about deceiving diagnoses we come
across in practice
 Below is an example

3.  33/F,overweight ,
followed up in opd for few days for symptoms of
palpitations
apprehension
right sided upper chest pain and
occasional right rib cage pain
symptoms aggravated on deep inspiration
DOE III NYHA
 Pulse 118/min,regular & equal BP = 126/86 mm hg
Mild pallor
RS - Clear, CVS - no murmur,
P/A & CNS - NAD
 ECG - sinus tachycardia (HR 120/min)

4. Past History
 No Past H/O Any Significant illness
 No k/h/o DM/HTN/CAD/COPD
 No Significant Family History
 Drug History
- Antibiotics,NSAIDS,PPI,Anxiolytics in last week
- OC Pills since 1 ½ years
- No known Drug allergy

5.  Already she had consulted 2 doctors for same
 My primary DD
1. Rt Pleurisy
2. Functional Pain
3. Many other DD like Anaemia,hyperthyroidism etc

6. (To be honest,like many other clinicians,when we
don't understand cause to symptoms,we tend to
label Psychological/Functional reason to pts
symptoms,I am no different and thought it may b
her anxiety)
However her Tachycardia to my clinical acumen
made me admit her just for observation and send
to general wards

7. Day 2 of Admission
 Tachycardia persisted,she found to have mild
Anaemia (Hb 8 gm%)
I labeled tachycardia is for Anaemia (I thought
why I admitted her )
 Still for work up, her Chest X-ray was done which
showed no abnormality
 Just that she had right ribcage pain and mild
tenderness in Rt Hypochondriac region (Again I
am assuring myself that it's her anxiety) ,she
was advised her USG Abdomen

8. The Red Flag
 USG Abdomen showed echogenic areas in liver
and minimal Rt pleural effusion
Radiologist suggested may be liver
infarct/contusion
 And it alarms all us treating Drs in Hosp
Immediate CT advised
It showed ? Lung Infarct (detailed report attached )

10. Sherlock Holmes work
 CT Abd,Pelvis # ? Lung infarct
 CT Pulm Angio # B/L Pulm Thromboembolism
 2 D Echo – Normal study
 B/L LL Venous Doppler # Few echogenic strands in
Left popliteal vein
(Only contributory significant history found was that she is
on OC pills for last 18 months)
 Rx given
LMWH - Warfarin

11.  After 6 months
- CT Pulm Angio # Complete resolution of old changes
& No e/o PTE
 Final Diagnosis #
Hypercoaguable State, Secondary to OC Pills with PTE

12. Lesson learned by me
 Symptoms of patient may be functional,
. . .but SIGNS ARE NOT !
 So If any sign is unexplained, keep searching the
cause...
You may never know what's beneath
(Keep all Doors & Windows Open !)

13.  Thanks for reading the Flow Presentation
 I found it was interesting and so shared !