Differential diagnosis

For those of you not in healthcare, a list of differential diagnoses is a way of considering all of the disease/condition options that explain the symptoms that a patient describes and/or that you see during a physical exam. Last week, I got scared by one of my differentials, but was so happy I knew enough to be scared, and follow up appropriately.

My patient was a 20 year old 39-week pregnant woman. She was there for her weekly pre-natal visit. While I washed my hands, I asked her how she was. There was a long pause and a sign on the way to saying, "fine." I didn't believe her, and said so. In a nice way, of course. That's when she started to cry, and tell me about her leg and how much pain she was in. This was not something I had seen in her chart that I had reviewed on her way in, so I sat down to comfort her and hear her story.

As it turns out, her legs had been swelling, and over the course of the previous week, had increased in size considerably. One of them was not only more swollen than the other, but she was having considerable pain in the the inner thigh region. Her jeans were significantly tighter than they were the week before. She had noticed no discoloration in her leg, upper or lower, or her feet. She did not have any tingling or numbness.

Since she wanted her cervix checked, and I wanted to see this leg undressed, I left so that she could do just that. The cnm I was working with was in seeing another patient, so I left a note on her desk to come see me ASAP. I was nervous.

Back to differentials. My differential diagnosis list included:

normal (but excessive) swelling of pregnancy.
DVT (deep venous thrombosis) or in english, a blood clot.

Maybe I should have considered others, but that DVT option scared the hell out of me, so right there, I wanted proof that this was not the case. The reason they are scary is that a clot in the leg can be released at any given moment and travel to the lungs (pulmonary embolism) or the brain (brain embolism) both which can be life threatening. NOT GOOD.

I went back into the room to assess her leg. As she'd said, no discoloration. Her legs were HUGE. I measured them both . . . the painful one was significantly larger in circumference than the other, but both were very swollen. Poor thing. After her cervical exam, I had her get dressed and sent her down to radiology to get a venous ultrasound.

An hour later, the terrific news arrived. NO DVT!!!

So I sent her home to rest WITH HER FEET UP until she delivers this baby. And hydrate. No more work for her!

I followed up with her again about 5 days later. She was still pregnant, but feeling better. Thank goodness.