An interesting lump, courtesy of Warfarin – a dilemma in clinical management

59 Year old female came in to ED due to a painful lump that she had noticed overnight in the right side of her abdomen, associated with pain in the right half of her abdomen, back and upper part of her hip. This was the vague and slightly confusing history on the card as I went to review her. She was a very pleasant lady, who walked into the cubicle without assistance, no support required – and clearly no hip pain?

She reported she had had a cough x 6 weeks – not continuous, but had had a chest infection initially, and was still recovering from that about 3 weeks back when she began to have productive cough and fevers again – and had to complete a second lot of antibiotics, the last of which finished yesterday. She still had bouts of cough though, even though it had improved considerably – one of which had happened last night just as she was going to bed. She couldn’t sleep all night due to the continuous coughing, but this wasn’t the reason why she was here that morning. She woke up in the morning feeling quite sore in her upper abdomen, and put that down to her constant coughing. She tried to ignore it, and took some paracetamol, but as she tried to dress herself, she felt that she required help with undressing and dressing, which was a concern. To top it off, she also noticed in the shower that morning that she had a palpable tender lump under her ribs, in the upper part of her abdomen on the right side. This concerned her enough to come to the hospital. Oh, and she was on warfarin – that lovely blood thinning medication that’s given for clots in the lungs or in the legs, or if you have a heart rhythm disturbance that makes you prone to throw clots to your brain – for recurrent PEs (clots on the lung) and her last INR was 2.6 (a test to see if the warfarin is doing what it is supposed to be doing, and whether it was doing more or less than it was supposed to be doing – recommended range for her condition was between 2.5-3.5)

When I examined her there appeared to be no bruising to the area in question, and her abdomen was soft, though there was definitely a palpable tender firm swelling in the right upper quadrant, sort of jutting out of the lateral aspect of her liver – my thoughts immediately went to a spontaneous hepatoma/bleed into her liver because of her being on the warfarin – I quickly ticked off in my mind a checklist of things that would signify severe ongoing bleeding internally, like pulse and blood pressure (both within normal ranges for her) and she appeared nice and ‘hemoglobin-y’ – adequately perfused! I decided to request a quick ECG (which was normal sinus rhythm) and did some baseline bloods on her including a clotting screen (to check her haemoglobin and INR today – both were normal, though a slightly raised white cell count and CRP) as well as a chest x-ray (I felt there were two reasons for this: 1) cough for 6 weeks gradually worsening, warranted radiographic evidence and 2) in someone presenting with tenderness of right upper quadrant, it is very relevant to be thinking about problems with the lower part of the lung above, rather than just focussing on the abdominal complaint – she may well have a pneumonia sitting in her right lung base, causing pain in her right upper quadrant! In this case, however there was nothing nasty on the chest x-ray on the right, though you could argue the left lung base looked slightly more hazy than I would have liked; at any rate, she needed treatment for an LRTI)

I spoke to my consultant, who quickly magicked an ultrasound machine within the ED and did what is called a ‘FAST’ scan, an ultrasound to quickly rule out free fluid within the abdominal cavity, usually done for patients of abdominal trauma to look for bleeding, etc. The scan was negative for free fluid within the abdominal cavity (we both breathed sighs of relief!), however we did find what seemed to be a collection of blood within the abdominal wall in the area of pain – she seemed to have bled into her abdominal wall, probably due to the coughing, which caused a tear within the muscle wall, and due to her being on the warfarin, caused her to bleed internally but contained within the wall of the abdomen – causing her presentation of a tender painful lump in her abdomen. Mystery solved. Now to the management of said mystery.

The dilemma we faced was this: We couldn’t stop her Warfarin due to the indication for which she was taking it in the first place – it could prove fatal if she had a clot on the lungs again. We couldn’t just leave her bleeding on the warfarin and do nothing. We needed to treat her cough as well, because even if it wasn’t life-threatening at this point, if she went on coughing, who knew how much worse this bleeding might get? And we had limited treatment options for her cough-slash-chest-infection, because many drugs including some antibiotics interfere with the action of warfarin, and the patient was allergic to penicillin (of course, we wouldn’t want this to be too easy!)

So we requested a formal ultrasound from the radiology department – much more detailed than our very ‘FAST’ scan. They agreed with our preliminary findings, with the very valuable additional information that there seemed to be no evidence of ongoing bleeding – the hematoma was contained and was not likely to worsen. Her INR was within the limits appropriate for her, maybe slightly on the higher side, so we decided to advise her to skip the next dose of her warfarin, and to liaise with the anticoagulant monitoring service to monitor her INR in the next few days to make sure it was still within the prescribed limits for her. We sent a sample of her sputum for culture and sensitivity, and based on the haziness in the left lung base and the raised inflammatory markers (CRP and white cells) we decided to start her on some antibiotics – she was allergic to penicillin, and so the next best option was clarithromycin which unfortunately interacted with warfarin so we couldn’t go down that route; we decided on doxycycline being the best line of treatment for her. We explained to her any of the red flag signs, if she experienced any concerning symptoms, to come straight back for review. We advised some analgesia, and some cough medication as well, and the patient was very happy to go home. Fingers crossed, she has neither returned nor have I heard of any problems coming to light following her ED visit.

This served as a learning experience for me – coming to a diagnosis in this case when the presentation was completely different from what was actually going on, and then connecting all the dots in the history (warfarin, chronic cough) and the physical examination (presence of a tender palpable lump in the absence of trauma) and ultimately finding out the mystery of the sudden lump, and then reaching a management plan that should have been so easy and straightforward, but really wasn’t due to the patient’s unique situation.

ortho/knee injury/major boo-boo

So some of you may recall in one of my previous blog posts, I saw a patient who had come in with a patellar fracture – avulsion fracture that happened when the ligament/muscle contracted and pulled off a small bit of the patella bone (also known as the kneecap). I got called to the consultant’s office recently because of this case – and I wanted to share a key element that I missed in my diagnosis/management that I wouldn’t want someone else to repeat.

So to recap (in case i am flattering myself and no one has actually read the afore-mentioned blog post :p) This was a 40 something year old male, with a football injury. Now when I say football injury, it wasn’t your usual contact trauma. No. He hadn’t played in a while, and without warming up very well, he began playing. He went in to kick the stationary ball, and as he pivoted on his left leg, and used his right leg to go in for the kick, he heard (felt?) a crack in his left leg which was basically his weight-bearing leg as he went in for the kick and he stopped there without being able to kick the ball. He was able to stay standing, but felt his knee go a bit wobbly and unsteady – ‘as if I couldn’t trust to put my weight on my knee, Doc’ – and so he laid himself down on the ground. He didn’t think it was extremely painful, but certain movements did make him prone to the occasional twinge of pain. He was able to hobble on the left leg, but unable to walk properly due to the unsteadiness of his knee joint. By the time he got to the ED and was seen by myself, it had been nearly 3 hours since the injury and his knee had become quite swollen. Not red or inflamed looking but definitely quite significant soft tissue swelling, with particular tenderness overs knee cap or patella bone. On examination, there seemed to be quite a doughy consistency swelling all around the joint, and even though he was able to flex the knee, he was unable to extend the knee fully without help (I assumed due to pain).

Even though there was no direct trauma to it (in that he hadn’t knocked the knee directly onto anything) and he could put his weight on it and walk (hobble?) on his own without support, made me question whether or not I should x-ray the injury. I did end up x-raying his knee, and to my surprise (I was surprised at how surprised I was!) found him to have had an avulsion fracture of his patella. I asked the ENP what needed to be done in this case, and she advised a cricket pad splint, with a fracture clinic referral for the next possible date. This was the last day of the week and so since this wasn’t apparently a clinical emergency, he was given an appointment for the fracture clinic for the following monday (3 days after the injury) and sent home with a cricket pad splint and crutches. He felt quite comfortable with this plan.

Fast forward to a few weeks later when as I mentioned the consultant asked me to see them in their office. Needless to say, I was scared I had made the ultimate boo-boo, and went though my mind every scenario of every patient I had seen recently that had seemed like it might lead to a conversation with the consultants (I am slightly embarrassed to admit many such cases came to mind) but when the consultant mentioned this case, I was surprised, I thought I had done good management there – assessed the patient, investigated and found a fracture, dealt with it and had also safety-netted him with a fracture clinic appointment. Where did I go wrong?

To be fair, the consultant quickly reassured me that there wasn’t any major issues ongoing. I hadn’t missed anything, on the contrary I had actually picked up something. The two things that needed to be learning experiences for me from this case were:

A) it was not just a patellar avulsion, the whole of the quadriceps tendon had become ruptured – the orthopaedic team had therefore complained that while they appreciated me picking up the injury, they would have liked to deal with it sooner than the 3-days-later non-urgent clinic appointment. I should have called the orthopaedic team on call at the time and gotten this patient seen by them and they would probably have admitted him overnight and done a surgical correction the next day (which was the management of this kind of injury) and while they appreciated my very detailed examination notes from the knee exam (even my own consultant was more than slightly happy at the knee exam!), I had failed to check – or document that I had checked! – the fact that the patient could not perform extension at the knee joint, which should have raised the possibility of patellar tendon rupture

B) Never, ever, EVER use cricket pad splints for…anything in the ED! I am supposed to be reading up on the use (or discouraged use!) of these in the ED and while I haven’t yet had the chance to read up on them, I have been advised to not use these for any injuries unless expressly advised by an orthopaedic or emergency medicine consultant. Check this space again later and I will update this blog post with the WHY of this.

A third aspect of the written complaint was highlighted by my consultant, I had apparently been promoted without being aware of it (this was said in slight jest by my consultant), as the orthopedic consultant felt that it was unforgivable for ‘an ST4 EM trainee (registrar level) to have missed such a crucial management point’ – I am only a lowly year 1 trainee currently!

Anyway, the take home messages from this incident need to be addressed and learnt, and while the patient did not suffer any adverse effects and got his surgery done, and there was no harm done, it is best to be aware of all protocols and nuances of management – and when in doubt, ASK!

A day full of bizarres

In any particular shift, there is a chance you will get to see a patient which an ‘unusual’ or downright weird presentation. Often it is a perception problem on the part of the patient, and usually things are amenable to reassurance and counselling. This particular shift was ‘unusual’ for a number of reasons: the sheer number of ‘unusual’ presentations packed into a single shift, and the distinct lack of faith in my *ahem* reassurances.


Case in point A – 28 year old female walks in to the department with sensation of a foreign body stuck in her throat. Fair enough, seems legit. She then proceeded to tell me how she had had some bacon last night (yes, more than 12 hours back) and she felt that it was too hard, and very chewy and when she swallowed it she felt as though it had gotten stuck somewhere in her throat (so many questions, like why did you eat it if it was so hard and chewy and difficult to swallow and how big of a bite did you take? but of course what I really asked her was…). Have you eaten or drunk anything since then and she said oh yeah, I have had some toast this morning, and have been trying to drink lots of water to wash it down with. Any vomiting? No. Any chest or abdominal pain? No. Any previous history of having things stuck in your food pipe when you swallow? NO. OK, so what do are your actual symptoms? Well I felt all night as if this was stuck in my throat somewhere, and so I am having difficulty swallowing and also I think I am choking on it because I am finding it difficult to breathe. To which I had to explain to her the concept of the two different pipes, one for the airway and a separate one for swallowing food and drink. I asked her if she had had a cough at all, to which she replied in the negative. I tried to reassure her that had anything gone down the wrong pipe she would not have been sitting here comfortably talking to me the next day, she would be quite distressed and, quite frankly – choking! She just stared at me as if I didn’t know what I was talking about. Anyway, needless to say, she didn’t buy my reassurances, and said she wanted me to look down her throat and pull it out. I tried convincing her that everything seemed to be clinically alright and there seemed to be no indication of anything stuck anywhere (except me in this situation!) but she was having none of it. I excused myself, and discussed it with my consultant, who agreed there didn’t seem to be any indication for further assessment, but advised me to speak to ENT, and whatever they say I could use to reassure the patient. I spoke to ENT who very kindly understood my predicament and volunteered to come down and speak to the patient themselves. They were also of the opinion that there was nothing in her throat that should not have been there, but they offered to scope her, and guess what they found?

N-O-T-H-I-N-G.

Yup. That’s right. No foreign body in her throat. And she very happily went home after that.


My next patient was by far the 2nd most bizarre occurrence of the day. Young 30 something male, walked into the department with an ‘unusual’ complaint. More of a request. He was known to have a hydrocele (a collection of fluid in the lining of the testicle, correctible with a small surgical procedure), and was waiting for an appointment for it to be surgically corrected. He missed his appointment for surgery for whatever reasons, and – get this! – he thought he would come in to ED to, and I quote: ‘Get it sorted today.’ *unquote*
I asked him if the condition had changed in any way or he had any new symptoms. No. Any fever or discharge? No. Any pain? a discomfort, yes but no actual pain, the discomfort had been going on for months now. Any abdominal pain? No. Any problems passing urine? No.
Well then I asked him quite frankly why he had come in to ED today? And he explained to me that he didn’t come in to hospital for himself today. His wife was in labour and he was just waiting to hear the good news, so he thought while he was waiting, he could pop in to ED to ‘get it sorted’. I explained to him that A) this wasn’t a case for the ED; B) I couldn’t give him an appointment for surgery even if I tried; C) did he think this was like a McDonald’s drive-thru? walk in to the ED, get an invasive surgical procedure done, walk right out? I examined him and assessed him fully, but I wasted no time in letting him know that the A&E was for exactly what it stands for: Accident and/or Emergency. I referred him back to his GP to sort out the appointment for him, possibly after his wife’s delivery. And I tried very hard not to blog about it then and there!


My third case (like I said, it was a series of bizarres, I kept waiting for someone to say ‘surprise! you’re on candid camera!) was that of an older female, in her late 50s, early 60s – who came in with a 9 week history of headache. Yes, NINE weeks. Gradually worsening, associated for the past 1 week with worsening neck pain and for the past 3 days with dizziness, nausea and vomiting, and that evening, she had gotten up off the toilet, felt very dizzy, walked out into her living area, and proceeded to lose consciousness for 10 whole minutes, unwitnessed but found by her husband who was in the next room and heard her fall. She now complained of feeling her legs were weak and numb, and that she couldn’t  moved her lower limbs of her own accord at all. She denied any back pain, there were no obvious signs of a head injury, and her sensations and power seemed to be intact, though generally weak in all muscle groups and not just the legs. Very non specific, but I discussed with my registrar the need for CT scan of her head. Oh, and she said she was worried because her mother had passed away at a young age due to a brain tumor. My registrar was reluctant to approve the CT head, but I suggested since I will document that this was long standing headaches, with sudden worsening, associated with loss of consciousness and some degree of neurological findings (however subjective they might be) that it would warrant a scan. It was then approved, and we got the CT scan sorted, trying to rule out a brain bleed. The scan was done, looked grossly normal, and per the medical guidelines, since a normal CT scan did not rule out a bleed completely, we admitted her under the medical specialty for observation and a lumbar puncture, which would check the fluid around the brain and spinal cord for evidence of the bleed, should there have been any. After the scan, as I explained all this to the patient, she became a bit nervous and looked visibly anxious at the prospect of a needle in her spine to extract fluid.
And as I stepped out of the cubicle and moved on to my next patient, I saw that, lo and behold, her lower leg weakness was miraculously cured as she got out of the bed ON HER OWN and then walked out for a cigarette. Sigh. She self-discharged herself after that, and walked out of the A&E on her own two fully recovered and recuperated legs. Fully cured of the headache and no signs of any of the weakness from previous. That wasn’t a waste of resources at all, was it?

Nightlife in ED: A series of ‘night’-mares – Part 1

I arrive at the night shift, change into scrubs and proceed on to shop floor – it’s not too bad – we get handed over 3-4 patients from the evening team, and I pick up my first patient – basically a minors patient, but since there is no ENP for the night: 40something male, no prior known comorbids, was playing football (yes, in this weather, and don’t get me started on the age!) went in for a kick with his right foot, all his weight on his left leg, and he suddenly heard a ‘pop’ in his left knee, since then has had difficulty walking or even bearing weight on the limb. Very swollen and tender anterior part of the leg (just 3 hours after this ‘injury’) but the mechanism isn’t direct trauma, so do I x-ray it? do I let it go? He is unable to weight bear, so I request one – would you believe he had an avulsion fracture of the patella! I am so glad I x-rayed it! Sent him home with a cricket pad splint (controversial, but that was our only option at the time) and a fracture clinic followup the next day. (More about this patient in one of my future blog posts)  My second patient is a young female who comes in septic (with septic observations – raised heart rate and a fever in this particular case), and I start figuring out the focus for her infection, which isn’t too difficult to ascertain: an infected surgical wound from a recent C-section she had, which looks (and smells) like it isn’t healing very well. Very quick and easy – antibiotics/fluids/sepsis 6 ticked off, and referred to the obstetricians (which was the Gynae SHO at this lovely hour), before moving on to my third patient: A young male who presented 6 hours after (yes, SIX HOURS AFTER!) being in an accident. He was stopped at a red light, and a car at unknown speed crashed into the back of his van. (yes, car … into THE BACK OF HIS VAN!) and then someone decided to crash into the back of that second car so he was jarred a second time. So he waited 6 whole hours before coming to ED at 2 am to be checked out. He complained of some shoulder pain, but had full range of motion and the mechanism wasn’t significant. I advised him to have some analgesia and go home. It was pointed out to me later on that he may only have been there for A) insurance reasons or B) so he could call in sick the next morning from work – being that he had been in hospital the previous night, or C) all of the above. Likely C. Anyway, the fourth: Elderly female, diagnosed with shingles 7 days ago started on treatment (which she had not taken!) and presented to ED because the pain was unbearable. I asked her if she had taken any pain-killers (she had not) and why she hadn’t been taking the amitriptyline (because it said on the leaflet ‘do not take if you have heart failure’ – even though her GP knew she had heart failure and had prescribed it for her and this warning is for people who usually take over the counter medications on their own) Bless her, the pain was more excruciating because the shingles rash was in her lower back, and the rash went into a skin fold, and everytime the skin folds rubbed onto themselves (as they usually do) or clothing touched it, it would burn. I empathised with her, told her how sorry I was that she was in this situation, but to expect that the pain will go away with time and that she needs to use her medication regularly, the rash itself was dry and not infected or anything, there was no other treatment for it. She didn’t like it, but that was unfortunately just the way shingles was. Unfortunately. Fifth: Barndoor chest pain, cardiac-sounding, first troponin 38 – started on ACS treatment, referred to medical specialty/cardiology for repeat troponin and further management/investigations – The sixth one was not really a patient I had seen, but was being handed over to me by one of my colleagues who was going off shift, and needed to hand over this patient to me to chase their CT scan report – if normal to be sent home with advice, if abnormal to be managed accordingly – the story will be unnecessary to relate here as the report came back 2 seconds later and he very kindly dealt with it himself (I did the discharge summary). Number Seven (or 6th?) was the cutest little old man, pleasantly confused dementia patient who had had an unwitnessed fall in his nursing home, and even though he denied any pain in his hips, there was a distinct grimace when you palpated his left hip, and his mobility had declined suddenly following to fall – Pelvic x-rays were requested, yet they appeared grossly normal. I gave him some analgesia and decided to refer him to the medical team because of his significantly reduced mobility following the fall, even though we could not find any significant injury, nor any significant cause for his fall (atleast not medically correctable in ED) – the medical team very kindly accepted the referral, understanding that this late hour meant he couldn’t go back home anyway, but also that he was unsafe till he was functionally fit to go back home as well. I then took a break (much-awaited) had some lunch (?dinner? breakfast?) at 4 AM – and felt exhausted, but the list went on: Eight – 74 year old female, known to have atrial fibrillation, who was brought in with palpitations and a fast heart rate – went through the mental checklist of things that may cause your heart to go fast – ruled it as infection as her WBC was 13 something, but her CRP was over 300! Very likely the focus was chest as she had reported a dry cough for the last week, that had x2 days back become quite phlegmy. CXR/bloods, including cultures/antibiotics and fluids prescribed – referred to medics.  Patient counselled at length because she was quite upset at having to be admitted (‘Doctor, can’t you just give me something to calm my nerves, and my heart will settle – I need to be home, it’s my daughter-in-law’s birthday tomorrow and I have to bring the cake!) and moving on…ninth on my list was my most interesting case of the night – middle aged female no prior known comorbids, with no personal or family history of epilepsy, brought in by paramedics and concerned family following what was very likely a generalised toniclonic seizure that she suffered in her sleep (she woke her husband up when he felt her shaking violently). The night before she was at her daughter’s wedding reception, and reportedly never drank alcohol. All her blood tests came back negative and her ECG and urine was fine (a urine pregnancy test was also negative). She had no focal neurology or anything else significant on her examination either. I discussed it with my seniors, and they agreed that something seemed very off about the whole case – we referred her to the medical specialty for inpatient observation as well as an inpatient MRI of the head, fearing the worst. The medical team agreed with the assessment, and were happy to admit the patient (usually patient with first seizures if their investigations in ED are ok and they are back to normal/usual baseline, and they have someone who can stay with them – we send them home with a followup to be seen in the ‘first-fit clinic’ as an outpatient). I counselled the patient and her family who understandably were very worried (they were very worried to begin with, but being admitted to be worked up for something sinister like what you would require an MRI head for worried them even more) – I answered all their questions and then once the patient was moved to the ward, I took a few minutes in the back room to compose myself. You do things on autopilot for so long, start of the shift to the very end, and you just keep moving forward from one patient to the next (often more than one) and there are times when one of those cases (or maybe all of them combined?) hits you right where it matters, because you are only human. I drank some water, took a deep breath – and moved on to number ten, very likely my last patient as there was about 50 minutes left till the end of my shift and all but one of the morning team had arrived. And I regretted picking up this patient at once: middle-aged male, admitted following an alleged overdose of 50 (yes. five. zero) grams of diazepam. I say alleged because reportedly he had taken them 3 hours back – and he was literally more awake than I was. Also, when I began to ask him what brought him to ED, he … just…started! Went on and on and on about everything under the sun – His divorce. His occupation. How he worked with the police. How he was a trauma surgeon for the past 26 years, how he knew the side effects of the medications he had taken. How he was also a scuba diving instructor. How he knew a certain celebrity. How he had been kicked out of his own house because his housekeeper had taken up residence there and had forged his signature on the papers and how he had a gun permit and not a gun but how he was framed for trying to murder his housekeeper who was still alive and the police won’t arrest him coz he worked with them and taught them scuba diving….*eyes going rolling backwards into their sockets* I interrupted about 5 times politely – but he went on. And on. And on. Not how you want to end your night shift (or any shift at any time!) Dealing with him felt like dealing with 5 different patients! And the alleged diazepam wasn’t making him sleepy or any less talkative either! I literally extricated myself from the encounter and almost ran to the phone to refer him to the medical specialty – not because I believed he had indeed overdosed on the amount he mentioned – but because he clearly needed psychiatric input/help (and now thanks to him, so did I!) I ran out of that shift like a bat out of hell – and as I exited the premises, one of my nursing colleagues, fresh as a daisy for her morning shift, yelled out ‘Bye darling, see you in a few hours!’ – reminding me that I was back again tonight, for the second of four consecutive nights. *Facepalm*

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.