“Get them out of here,” you hear your colleague next to you exclaim. “Treat ‘em and street ‘em. We need to open up some more beds.” You wrinkle your nose and wonder quietly if we’ve all become so focused on throughput that we’ve somehow lost sight of why we all signed up for this job in the first place. As if to put salt into the wound, one of your senior residents comes up with three new cases to present, but notes that all three are already “dispo’d” and just need your blessing.

You pause to listen to his stories and tell him, “Great. Let’s talk about what we can do to help some of these people.” Blessed with good insight and even better people-reading skills, your resident reconsiders his fast and furious approach and slows down the tempo just a bit. The first two patients were indeed relatively straightforward, and once you do a little bit of probing and drop a few “pearls of wisdom,” you are comfortable that he didn’t just perform superficial evaluations to keep the revolving door turning. You tell him you will go see those two patients next.

Happy that he’s two for two so far, your resident launches into the tale of his third patient. He’s a 56 year-old male who presents to the ED with left leg pain. A few weeks ago, he had an uncomplicated operation for perforated diverticulitis and intra-abdominal abscess management. Since then, he has noted increased left leg pain. The patient denied any other systemic symptoms including chest pain, shortness of breath, palpitations, fevers, chills, nausea, vomiting, abdominal pain, or lightheadedness. Your resident notes that the patient’s vital signs were normal and that the only significant clinical findings were a non-tender abdomen with a well healed surgical incision, and mild left lower extremity swelling. To summarize his assessment and plan, your resident goes on to explain that he performed a bedside ultrasound, diagnosed the patient with a DVT, started him on Lovenox, and called the medicine team for admission so that he could be bridged to Coumadin. The patient’s blood work results have been reviewed and the patient is in line to be seen by the medicine team.

Not wanting to miss a good teaching opportunity, you review the various management options available as your resident pulls up the images he obtained during the patient’s DVT scan. You finish your review of the various anticoagulation options and take a long, hard look at the DVT images he acquired.



What do you see in the image? What other images do you want to see? What else do you want to know about this patient? Conclusion on next page.



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