Erica Seiguer Shenoy

The patient was a middle-aged lady with a history of deep venous thrombosis (DVT), a condition in which blood clots form in the large veins of the leg. She also had a history of pulmonary embolism (PE), the migration of blood clots to the lungs.

She had first had a DVT many years ago and then none for 20 years. That is, until the previous autumn, when she was at another hospital for an unrelated reason. In that setting, she was not placed on DVT prophylaxis. Most patients who are at all immobilized in the hospital are placed on medication aimed at preventing the formation of DVTs. A week after leaving the hospital, she developed leg pain and swelling and shortness of breath. She was found to have a DVT and PE, and because this was her second occurrence, she was started on lifelong anticoagulation with warfarin (Coumadin). As a consequence of the DVT, she had continued leg pain and had seen several specialists in consultation, with little to no relief.

On the night I admitted her, as the night float on the private medical service, responsible for admissions of patients once the interns on service had reached their “caps,” or maximum number of patients admitted, she had been seen for an outpatient consultation. There, she complained of shortness of breath and chest pain, as well as leg pain. Given her history, she was sent immediately to the emergency department. There, a CT scan was done to look for DVT and PE, but it was of poor quality and not definitive. Ultrasound studies of her legs showed no clot, so no DVT. The plan, from the emergency department physician pass off, was to perform another CT scan and treat for likely PE.

I reviewed her medical record, which was brief since she had been put into our system only recently. As I entered the room, I noticed a pleasant-appearing lady speaking with her nurse. I asked if I could sit down and listen while the nurse finished her initial intake.

When I started asking questions, the patient recounted her feeling of shortness of breath, her otherwise relatively uncomplicated medical history, and her current medications. I asked more questions—specifically regarding what she had been told about why she might have this tendency to form blood clots. I knew she had one teenage daughter, and I asked if she had had any miscarriages. She said yes, she had, actually, four miscarriages. Her mood shifted slightly and she told me how the last baby she had miscarried would be 12 years old now. She started to cry and then, looking at me and at my pregnant belly, apologized. “I don’t mean to upset you,” she said. I was visibly pregnant at the time, a month shy of delivery. I assured her that there was nothing to apologize about. I told her I could only imagine the loss she endured.

At that moment, I had the feeling there was something more on her mind. I asked her how she was coping with her health problems. She looked at me and started to recount how difficult things had been at home because of her constant leg pain. She feared for her family’s financial situation with her husband as the only breadwinner, for her relationship with him and with her daughter, from whom she tried to hide her pain. Her husband, she told me, had told her not to worry, that they would get through this and to just concentrate on getting better. I asked her some of the standard depression-screening questions about mood, sleep, concentration, interest in activities, and finally, if she had ever thought about suicide.

She recounted an episode in the last month in which she had thought of taking an entire bottle of pills prescribed for her leg pain. She had a hand full of the pills and at the moment she was about to take them, something stopped her—her faith in God. She was crying. I reached over and held her hand. She recounted a second episode during which she doubled or tripled her pain medication dose with the hope that she would just “not wake up.” After taking the increased dose, she told her husband, who watched her throughout the night. She spoke with one of her doctors the following day, who referred her to her primary care doctor, who then started her on a low-dose antidepressant.

I asked her if she felt safe to go home, given her access to medications. She was not sure if she could trust herself, she admitted to me. I affirmed the difficulty of her situation and proposed a plan. First, we had to address the possibility of a pulmonary embolus. Second, I told her I thought she needed to see a psychiatrist while in the hospital. She was hesitant. She told me she was worried about the appearance of seeing a psychiatrist. Growing up, she was told that only “crazy” people see psychiatrists. In retrospect, she told me, she probably had depression her entire life. She agreed reluctantly to speak with a psychiatrist.

It was nearing 3 a.m. when we’d finished. I told her to try to get some rest and I’d let her know the results of the blood tests. I also told her that as the night float, I would be handing off her care to the primary team in the morning. A few hours later, when the blood test came back negative, I stopped by her room to tell her the good news. She was relieved. I wished her the best of luck and told her I would be sure to communicate everything we’d discussed to the primary team that had just arrived.

I met with the intern who would take the patient on to his panel that morning. I gave him a full presentation of the patient and emphasized my concerns about her suicidal ideation, suggesting that he contact psychiatry first thing in the morning. My concern was that we had a small window of opportunity during which she would be receptive to seeing a psychiatrist, and we should make the most of it. I double-checked that my note was in the computer and the paper chart, the orders were in, and there were no loose ends.

Walking home from the hospital that day, tired from being up all night, I thought over how much I’d learned about this patient, the intimacies of our conversation, covering everything from her miscarriages to her strained relationship with her husband, her financial difficulties, her belief in God, and her anger and later forgiveness toward the doctor she blamed for not putting her on DVT prophylaxis almost a year earlier. In this case, the social history was, in many ways, the key to the patient’s presentation.

Erica Seiguer Shenoy, MD–PhD ’07, is a resident in internal medicine at Massachusetts General Hospital.