Inconclusive Scan results?

[vengaaqui]

Let's say moderate probability for PE morbidly obese patient who presents for shortness of breath, chest tightness, left sided chest pain radiating to back. You get the CT scan and it's inconclusive (no major lobar PE, but can't say **** about segmental or subsegmenfal due to respiratory motion artifact and body habits). Doppler of legs inconclusive as well do to body habitus with even the femorals not fully visualized. Do you send home with a "good luck", obs with maybe echo +\- VQ? I ultimately obs admitted the patient but kind of feel stupidly conservative by the hospitalist's response?

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[EMDOC17]

I guess it would depend on each situation. If this patient was hypoxic then easy admit. If this patient is 95%+ on room air then I would probably d/c home. Maybe it is a bit brass but we can only do so much testing. You got the testing that you needed and it had results that are the best you can get. If the guy ends up having a PE well damn that sucks. Maybe they come at you in court that you should have observed the patient and gotten the V/Q that likely would have been inconclusive as well. I figure if I get it a darn good shot and try my best to r/o a disease I can send that patient home.

 

[Rendar5]

Let's say moderate probability for PE morbidly obese patient who presents for shortness of breath, chest tightness, left sided chest pain radiating to back. You get the CT scan and it's inconclusive (no major lobar PE, but can't say **** about segmental or subsegmenfal due to respiratory motion artifact and body habits). Doppler of legs inconclusive as well do to body habitus with even the femorals not fully visualized. Do you send home with a "good luck", obs with maybe echo +\- VQ? I ultimately obs admitted the patient but kind of feel stupidly conservative by the hospitalist's response?

If you're testing probability is still not minimal then you have got to admit

 

[deleted109597]

If you're testing probability is still not minimal then you have got to admit

Meh.
If you feel that strongly then you can anticoagulate them and send them home anyway.

 

[Rendar5]

Meh.
If you feel that strongly then you can anticoagulate them and send them home anyway.

Don't really send PE's home. Let someone else take the risk. Seen too many unpredictably decompensate. Of course this is a low risk pt so I assume the only reason a CT was obtained was due to a positive d-diner. So i have to assume the guy is moderate risk anyway

 

[deleted547339]

Admit for acs r/o. Next patient.

 

[WilcoWorld]

Admit for acs r/o. Next patient.

Yeah, in the above case, I'm still worried about ACS.

If I thought that the patient was sick, I'd admit.
If I thought that the patient was fine but has too much adipose tissue for me to prove it, I'd discuss the RISKS vs benefits of admission. Then I document the shared decision making and go with what the patient preferred.

 

[OccupyTheED]

Let's say moderate probability for PE morbidly obese patient who presents for shortness of breath, chest tightness, left sided chest pain radiating to back. You get the CT scan and it's inconclusive (no major lobar PE, but can't say **** about segmental or subsegmenfal due to respiratory motion artifact and body habits). Doppler of legs inconclusive as well do to body habitus with even the femorals not fully visualized. Do you send home with a "good luck", obs with maybe echo +\- VQ? I ultimately obs admitted the patient but kind of feel stupidly conservative by the hospitalist's response?

Don't ever let the hospitalist response affect your decision making. I've been out only 15 months now and had far too many hospitalists scoff at admission only to have those same patients have prolonged and complicated inpatient courses of a bad outcome within 30 days. The hospitalist, especially at night, isn't always going to be interested in the best thing for the patient