Addressing Urgent Clinical Concerns Without Complete Diagnostic Results
In the absence of diagnostic test results, you should prioritize treating any potentially life-threatening conditions that require immediate intervention based on clinical presentation alone, particularly if pulmonary embolism is suspected. 1
Assessment of Urgent Conditions
- For patients with suspected high-risk pulmonary embolism presenting with shock or hypotension, immediate intervention is warranted without waiting for complete diagnostic test results 1
- Bedside transthoracic echocardiography showing right ventricular dysfunction in an unstable patient is sufficient evidence to prompt immediate reperfusion therapy for suspected PE 1
- If clinical suspicion for PE remains high despite pending diagnostic tests, treatment should be initiated promptly as delayed diagnosis significantly increases risk of mortality 1
Conditions Requiring Immediate Treatment
- For suspected high-risk PE with hemodynamic compromise, immediate anticoagulation should be started before diagnostic confirmation is complete 1
- In patients with suspected deep vein thrombosis (DVT) and high clinical probability, finding a proximal DVT on compression ultrasonography is sufficient to warrant anticoagulant treatment without waiting for additional PE testing 1
- Active babesiosis with identifiable parasites on blood smear or positive PCR should be treated immediately due to risk of complications, particularly in immunocompromised patients 1
Diagnostic Test Management
- Failure to follow up test results is a critical safety issue with rates of missed follow-up ranging from 20-61% for inpatients and 1-75% for emergency department patients 2
- Diagnostic tests are most valuable when ordered to confirm clinical suspicions raised during history and physical examination rather than as unfocused screening 3
- When diagnostic uncertainty remains despite initial testing, the term "provisional diagnosis" should be used, and treatment decisions should be guided by disease severity and behavior 1
Specific Testing Considerations
- For COVID-19 testing, if clinical suspicion remains high, a negative antigen test result should be confirmed by standard NAAT (PCR), as antigen tests have a pooled sensitivity of 81% 1
- V/Q scanning is a valid alternative to CT pulmonary angiography for patients with contraindications to CT contrast or in younger patients to reduce radiation exposure 4
- D-dimer measurement combined with clinical probability assessment allows PE to be ruled out in around 30% of patients with a three-month thromboembolic risk of <1% in those left untreated 1
Follow-up Planning
- Schedule a timely follow-up appointment specifically to review pending test results 2, 5
- Consider the use of patient portals for test result communication, as immediate release of diagnostic test results has been shown to increase patient viewing of results within one day 5
- For patients with suspected PE who cannot undergo immediate definitive testing, arrange for lower limb compression ultrasonography as finding proximal DVT is sufficient to warrant anticoagulant treatment 1
Common Pitfalls to Avoid
- Delaying treatment of potentially life-threatening conditions while waiting for diagnostic confirmation can lead to preventable morbidity and mortality 1
- Failing to establish a clear follow-up plan for pending test results increases the risk of missed diagnoses 2
- Overreliance on negative screening tests when clinical suspicion remains high can lead to missed diagnoses, particularly for conditions like PE where test sensitivity varies 1, 6