62 year old male, known to have rheumatoid arthritis, on naproxen for it regularly, attended ED with the complaint of discoloration and numbness of the right ring finger; he turned out to be a lesson in management.
Upon my review at 7AM, the patient had been in the department about 2.5 hours. He reported that he wore heavy gloves (his usual) at work (works in the produce section of Tesco’s) and he removed his gloves at around 1AM and noticed the ring finger of his right hand to be darker coloured than the rest of his hands. It was painless and he didn’t recall bruising or injuring it in any way. He thought nothing of it, and put it down to his glove having rubbed off some color on to his finger. 3 hours later, his manager examined his finger and noticed it was colder than the rest of his hands. He was then advised to attend ED. When I saw him, a good 6+ hours had passed since he first noticed the discoloration. There was absolutely no pain, no history of trauma, on examination, there was a significantly darker discoloration of his ring finger, isolated, also appeared slightly swollen, had full range of motion, and capillary refill could not be assessed because the finger did not blanch on pressure. Radial and ulnar pulse were palpable of the affected arm. There was no sensation loss at the ring finger. There wasn’t any tourniquet effect of anything like a tight glove or a ring. He denied any drugs of abuse, had never smoked in his life and was not allergic to anything. He had no prior history of any such symptom, no prior personal or family history of any clots or bleeding or vascular disorders. To make matters slightly worse, he had injured himself in some accident, causing a deformity of the distal phalynx of this finger, with a rudimentary distorted nail bed.
All his observations were within normal limits. There wasn’t much else of note per examination. Are you on board this thought process with me?
I was at a loss to figure out what was going on and what was causing this patient his symptoms. He felt fine within himself. He actually found it quite funny that I couldn’t figure out what was going on. I went through all differentials of this sort of symptoms, but it didn’t fulfil any criteria for …anything. It didn’t look like an arterial ischemia, because it wasn’t pale, nor painful. It did look like venous congestion, but I could not for the life of me figure out why he would suddenly have an isolated venous congestion of just a single digit. And also, since it had been 6-8 hours since symptoms started, was there anything else I could do? I Decided to seek senior advice.
I excused myself, and went to ask for senior support. I discussed it with a register, who kindly came in, examined the patient, spoke to them, excused themselves and…asked a second registrar (there were no consultants available at that time) He also came in, spoke to the patient, etc etc… and to the mirth of the patient, all FOUR of the doctors who came in were equally stumped. The last registrar advised after seeing the patient himself to send him home, and to recall to the consultant review clinic the next day, as he felt this was not vascular in origin. I did as I was advised. Documented everything and sent the patient home. Patient was also happy with this plan. Was still laughing as he left, thinking he was some sort of medical marvel (he was!) who had confused all the doctors (he had!)
I still wasn’t happy, as even though we had done all we could, I had been no closer to finding out the how or the why or even the what behind the patient’s bizarre presentation. I then went to the consultant when they came on shift a while later. She did sort of freak out that i wanted to seek advice about a patient AFTER I had sent them home. I told her that I had sought the advice of whoever was available to me at the time, but since that still left quite a few unanswered questions (what why how) I wanted to know what she would have done in my place, or atleast what she would have advised me had I had the opportunity of asking her at the time.
Now thinking about it, and having discussed with the ED consultant, I have a better plan of action: I should have discussed it with vascular surgery, and sought their opinion. I also probably should have considered investigating for a cervical rib, something she strongly suggested.
A cervical rib is an extra first rib, that can potentially cause pressure on blood vessels or nerves as they arise in the arm and may cause symptoms distally down the arm. This case doesn’t really suggest that sort of presentation, but still it would be worthwhile to do it for completeness.
An assessment or opinion from vascular surgery would have been optimum. I did end up speaking to vascular surgery after the patient left, to ask them for further advice. They advised that since they hadn’t seen the patient, they would have recommended ruling out a cervical rib (surprise!), and giving a stat dose of enoxaparin, and sending him home on apixaban, and recalling him in for a vascular surgery review within a week. I discussed this plan with my consultant who for the first time during this whole debacle, agreed with me that anticoagulation in this particular case was not indicated.
In my defence, I thought at the time I was doing the right thing, I was confused as to how to proceed further and so sought senior help from the sources available to me; it was more than one source!
I now know that I had the option of asking for specialist advice as well, which even if I disagreed with their plan would have guided me a bit further and made me more confident in that I had utilised all the resources available to me in order to optimally manage what turned out to be a very confusing patient.
The patient turned up the next day, and the consultant reviewing him went through my notes, but could not understand why I had been so concerned as to call him back for a review. As the patient’s symptoms had somehow magically vanished over the course of 24 hours, all that was left was a slight discoloration – no swelling, no movement problems and definitely no numbness or congestion or schema. Hallelujah!
If anyone has any bright ideas about how they would have managed this case, please let me know in the comments section. I really should start taking pictures of these bizarre presentations, and uploading them here, as for some reason, they do magically disappear and all that is left is my description of it! Anyways, do let me know about your thoughts.