An interesting case – if I had just connected the dots

Always probe more. And I mean it in the inquisitive, analytical way (but I appreciate the way your mind works! *wink wink* *nudge nudge*) Never take anything for granted, and if you feel your gut telling you something, it might be a good idea to listen to it.

Case in point: I was on a clerking shift a few months back during my Acute Medicine rotation. My next patient was a 37 year old female, who had presented to ED with a headache of 2 days duration, and ED had referred her to medicine for admission because of her very significant past medical history. 1 month ago she had suffered a stroke, an ischemic infarct. Yes, I found that very hard to believe as well so I looked through her hospital records and sure enough she had had an infarct in one of the areas of her brain, leaving her with significant left sided weakness, a weakness that had since then improved quite a bit, but she still required a cane to walk, otherwise she was fully independent. She also was on a significant amount of pain medications due to degenerative disc disease , and she had long-standing sciatica. She also had a long-standing skin condition, that I was unable to ascertain, and she did not know the name of. She had recently had that biopsied and was still awaiting the results of that biopsy.

Her admission today was indicated because her previous stroke had begun with a nasty headache in a similar location. It began 2 days back, and even though she noticed no new neurological symptoms, she sought help from her doctors, who referred her to ED, who referred her to us. Something did not set quite right with me and I probed further, asking about any early pregnancy losses etc (yes, I did think about the antiphospholipid syndrome, it was on my differential list for a young patient with thromboembolic phenomenon like a stroke, and I was looking for other clues to reach a conclusion). She told me she had 1 daughter, 5 years old, and that the daughter was a twin, and her sibling had passed away during or just after delivery. And here I must admit I stopped the probing nature of my questions, and did not ask about any further pregnancy losses, I just assumed since she told me about the loss of a child, she would have mentioned any other such incidents. I advised some pain killers and a CT scan, baseline set of investigations.

Enter my consultant, who was coming in to do the post-take ward round. I briefly told him the summary of the case. The first question he asked was, any previous early pregnancy losses. I said no. He went in to her, asked her the same question directly. To which she nodded her head and informed us that she had had 2 miscarriages early trimester, and that her maternal uncle and aunt both had DVT/PE and maternal grandfather had passed away after a massive stroke at age 47. On examining the patient, the consultant noticed the rash, commented on it as being very likely the livedo reticularis that is seen in cases of antipospholipid syndrome, and turned around and gave me a look which clearly meant to say ‘We will investigate further, but I have no doubt that this is antiphospholipid syndrome.’

We called in haematology, and rheumatology, who agreed with us. We sent off a panel of studies including anticardiolipin antibodies and lupus anticoagulant. And started the standard treatment for it.

I almost missed this case because I did not probe further, when I knew I was on the right track. Granted, I did not know about the rash being classical for it, but I was still headed in the right direction, till I backtracked because I took information for granted.