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Tye-Smiley v. Ohio State University Wexner Medical Center

Court of Claims of Ohio

June 24, 2019

CHELLI TYE-SMILEY, Admr., etc. Plaintiff

          Sent to S.C. Reporter 7/22/19



         {¶1} Plaintiff, individually and as the administrator of the estate of Eddie Smiley, brings this action for wrongful death and survivorship arising from Smiley's death on February 19, 2015. The case proceeded to trial before the undersigned magistrate.


         {¶2} Cheryl Moore testified that at all times relevant she was employed as a nurse at Richland Correctional Institution, where Smiley was an inmate in the custody and control of the Department of Rehabilitation and Correction. Although Moore had no specific recollection of Smiley, she testified about medical records showing that she provided care to him in January 2015. Moore stated that progress notes and infirmary assessments that she made on January 27, 2015, show that she attended to Smiley while he was under observation in the infirmary with a complaint of pain in his right thigh which he rated as 5 on a scale of 1 to 10, and that while he said there had earlier been some intermittent pain radiating down to the right calf, when she saw him he had no calf pain. (Plaintiffs Exhibit 1, pp. 39, 155.) The medical records reflect that Smiley was using a walker to ambulate, Moore stated.

         {¶3} Progress notes and infirmary assessments show that Moore next saw Smiley on the morning of January 29, 2015, when he was still under observation in the infirmary, she stated. (Id., pp. 41, 159.) As Moore documented, Smiley complained of pain in the right hip and thigh which he rated as an 8, and that after he stretched his right leg earlier his calf felt tight. Moore stated that she would not have been present when, according to progress notes, Nurse Practitioner Christine Ungar saw Smiley later that morning and decided to have him transported by van to defendant's emergency department. (Id., p. 41.) But, Moore explained, after Unger wrote an order to have Smiley taken to the emergency department, she signed it to acknowledge reading it. (Id., p. 25.) Moore stated that her role would have then been to document Smiley's vital signs, which she recorded on an Emergency Assessment form that accompanies inmates when they go to outside facilities; the form also set forth Ungar's description of Smiley. (Id., p. 162.) Moore stated that Ungar or another advanced level provider would have been responsible for gathering any other documents to send with Smiley.

         {¶4} Christine Ungar testified that at all times relevant she worked for the Department of Rehabilitation and Correction as a nurse practitioner at Richland Correctional Institution. Ungar stated that Smiley's medical chart shows that she saw him on January 5, 2015, for multiple complaints, including left knee pain that he attributed to having slipped and fallen on ice, and low back pain with radiculopathy that he attributed to ankylosing spondylitis, a chronic inflammatory disease that he had. (Id., p. 36.) The medical records appear to show that Ungar next saw Smiley on January 28, 2015, she stated. From Ungar's review of the records, Smiley had been in the infirmary for at least the preceding two days under the care of a physician who asked her to look after Smiley in his absence. Ungar noted that when she saw Smiley he was in discomfort and needed an assistive device to ambulate, whereas he had been able to walk under his own power when she saw him earlier that month. (Id., p. 40.) Ungar stated that she prescribed a one-time injection of Toradol for pain relief and saw no need to deviate from the plan of care put in place by the physician, who had ordered, among other things, an EMG to test the nerve function in the lower extremities, strengthening exercises for the back, and pain medication.

         {¶5} Ungar testified that progress notes indicate she saw Smiley again the following morning, on January 29, 2015, at which time he complained of low back pain radiating down the right hip and into the thigh and calf. (Id., p. 41.) Smiley complained, she wrote, that his pain was worsening every day and that his leg felt heavy, and she observed that the right calf was slightly larger than the left and that the right lower extremity was tender to palpation. In her assessment, Ungar stated, she felt Smiley was at an increased risk of developing a deep vein thrombosis (DVT) due to his ankylosing spondylitis, the amount of time he was spending in bed, lab results showing an elevation of his erythrocyte sedimentation rate (ESR), and the inability of pain medication to relieve his symptoms. Ungar explained that she decided to send Smiley to defendant's emergency department to be evaluated, especially to evaluate whether his symptoms were being caused by a DVT versus radiculopathy. Ungar ordered a dose of the pain reliever tramadol and wrote an order to have Smiley transported out that included the term "R/O DVT." (Id., p. 25.) Ungar stated that in the Emergency Assessment form that would accompany Smiley she noted his medical history and complaints and her findings; she did not specify in the form that she wanted to rule out a DVT, nor did she note any calf symptoms, she explained, because she deferred to defendant to perform a workup and rule out all differential diagnoses. (Id., p. 162.) Ungar had no involvement in Smiley's care once he left the prison, she stated.

         {¶6} Shabbir Matcheswalla, M.D. testified that he has been employed with defendant since 2011 as an Assistant Professor of Clinical Medicine, and is board-certified in internal medicine. Dr. Matcheswalla described his education, training, and professional background, and stated that he is Vice Chair of defendant's Clinical Operations Committee, which is charged with creating and making operational changes to increase efficiency and workflow and ultimately patient care.

         {¶7} Dr. Matcheswalla, a hospitalist, explained that he admitted Smiley to the hospital early on the morning of January 30, 2015, after Smiley was seen in the emergency department. An admitting hospitalist, Dr. Matcheswalla stated, performs an initial assessment of patients based on their history and a physical examination, and then manages their care and orders diagnostic testing where appropriate. For patients admitted from the emergency department, his initial assessment would generally include a review of the records from the emergency department. Developing a differential diagnosis is also part of the process, Dr. Matcheswalla explained, meaning that he identifies a framework of potential diagnoses based on the chief complaints of the patient-oftentimes before he sees the patient-to hone in on what questions to ask the patient and then try to rule out certain diagnoses through examination or testing. In Dr. Matcheswalla's explanation, identifying differential diagnoses is different than suspecting a diagnosis, as it is a broader consideration of potential diagnoses, but differential diagnoses may be indexed in order of high to low clinical suspicion.

         {¶8} Although Dr. Matcheswalla did not recall Smiley, from his review of the medical records his chief differential diagnosis was that Smiley's symptoms were caused by ankylosing spondylitis. Dr. Matcheswalla acknowledged that ankylosing spondylitis was not a condition he saw often and this was one of the first patients in whom he suspected an exacerbation of the disease. Looking at the History & Physical notes he made, Dr. Matcheswalla explained that he felt elevated inflammatory markers, including ESR and CRP (C-reactive protein), in the bloodwork fit that explanation. (Defendant's Exhibit B, p. 13.) As Dr. Matcheswalla noted at the time, Smiley had already been seen for an orthopedic consultation in the emergency department which found there was low suspicion for a septic hip. The doctor who performed the consultation, though, noted that Smiley reported his symptoms were different than his usual flares of ankylosing spondylitis; Dr. Matcheswalla also noted Smiley reported normally having uveitis (eye inflammation) during flares but not this time, and that Smiley said it was abnormal for him to have leg pain during a flare. (Id., pp. 14, 17.) Dr. Matcheswalla stated that he prescribed prednisone to reduce inflammation and requested a rheumatology consultation since this was a rare condition he was not very familiar with. Dr. Matcheswalla testified that he ordered an MRI of the lumbar spine to look for inflammation which would help solidify a diagnosis of an ankylosing spondylitis flare and he requested a physical therapy consultation to assess the patient's mobility, a common practice to determine the patient's disposition upon discharge from the hospital. And, Dr. Matcheswalla testified, he prescribed Ultram for pain relief and noted that Smiley would continue taking his regular doses of methotrexate and folic acid for managing the ankylosing spondylitis. Finally, Dr. Matcheswalla stated, he prescribed subcutaneous heparin as a DVT prophylaxis, as this was standard protocol for all patients admitted to the hospital.

         {¶9} The concern with a DVT, Dr. Matcheswalla explained, is that it may travel from the deep vein where it originates, i.e. in the leg, and travel to the lungs, where it can lead to a fatal blood clot. Dr. Matcheswalla, who had no recollection of Smiley, stated that he typically reviews patients' charts before seeing them, and, from the information available to him in this instance, particularly the unilateral leg pain noted in the prison's Emergency Assessment form and the emergency department records, at least initially a DVT would have been somewhere among his differential diagnoses. Dr. Matcheswalla stated that upon examining Smiley, however, he concluded Smiley's complaints were probably resulting from ankylosing spondylitis and he did not suspect a DVT, making no reference to it in his written differential diagnosis or other notes. The most common signs of DVT in the calf are pain, swelling, and erythema (redness), Dr. Matcheswalla stated, and nowhere in his History & Physical notes did he identify such symptoms in the calf. (Id., p. 14.) Dr. Matcheswalla stated it is important that an admitting physician perform a thorough exam and record an accurate history, and if Smiley had calf pain he would have noted it. Dr. Matcheswalla also testified that Smiley did not have risk factors for a DVT, other than perhaps immobility. Dr. Matcheswalla acknowledged that patients can have multiple conditions at the same time and that having an exacerbation of ankylosing spondylitis would not rule out a DVT, nor would a knee effusion, which Smiley also had. Asked whether ankylosing spondylitis increases a patient's risk of a DVT, Dr. Matcheswalla did not know. Dr. Matcheswalla was also asked about a DVT prevention policy or guideline of defendant's under which he stated that Smiley would have been in the moderate to high risk category, which would call for prophylactic medicine, which Smiley was getting, as well as ambulation. (Plaintiff's Exhibit 14.) Dr. Matcheswalla stated, though, that if he is concerned about DVT as a potential diagnosis, he would apply the Wells Criteria for assessing the risk, which sorts patients into either a low or high-risk category, and if a patient has a low likelihood under the Wells Criteria and low clinical suspicion, there is no need to test for a DVT.

         {¶10} Allison Heacock, M.D. testified that she is board-certified in internal medicine and pediatrics and has held appointments with defendant since 2012 and with Nationwide Children's Hospital in Columbus since 2015. Today, Dr. Heacock explained, she splits her professional time between serving as a hospitalist with defendant, seeing patients at Nationwide Children's Hospital, and teaching. Dr. Heacock explained that during the relevant time period in 2015, which was prior to her joining the Nationwide Children's Hospital faculty, she spent 80 percent of her time in clinical work as a hospitalist, and 20 percent devoted to teaching and mentoring. Dr. Heacock recounted her educational and training background and her professional history with defendant, including service on multiple hospital-wide committees. Dr. Heacock acknowledged her medical license was suspended several years earlier and gave a forthright explanation that had no connection with patient care.

         {¶11} Dr. Heacock testified that progress notes establish that after Dr. Matcheswalla admitted Smiley to the hospital early on the morning of January 30, 2015, she attended to him for the first time later that day. (Plaintiff's Exhibit 2, p. 46.) Dr. Heacock explained that Smiley was having chest pains and palpitations. In a progress note, Dr. Heacock charted her plans for addressing four areas of concern, including tachycardia (elevated heart rate), pleuritic chest pain, right knee enthesitis (inflammation), and ankylosing spondylitis. For example, Dr. Heacock took steps to rule out heart problems, and inasmuch as Smiley indicated that he thought a dose of prednisone he was given during the orthopedic consultation was causing some of his symptoms, she lowered his dosage. Dr. Heacock related that she recommended antiinflammatories to address the ankylosing spondylitis, and, she also explained, pleuritic chest pain is a relatively benign inflammation of the lungs commonly associated with ankylosing spondylitis.

         {¶12} Dr. Heacock explained that the swelling she observed at that time was limited to the knee, being inside the joint and on top of the kneecap, giving the knee a large, puffy appearance. As Dr. Heacock noted, the orthopedic consultant had already examined the knee and her plan was to order a rheumatology consultation and steroid injection, and if the pain persisted she would order an MRI. Whereas Dr. Heacock documented symptoms in the right knee, she related that there is nothing in her progress notes from that initial examination, nor during her subsequent encounters with Smiley over the course of her time serving as his attending physician, reflecting swelling, tenderness, or redness in the calf, which she stated are signs of DVT. Dr. Heacock testified that, based upon her notes, she does not believe that she viewed DVT as a differential diagnosis; otherwise, she would have documented it as such and ordered testing to rule it out. Dr. Heacock's only reference in her progress notes to DVT was to document that Smiley was receiving heparin as a DVT prophylaxis.

         {¶13} Dr. Heacock recounted that the next day, January 31, 2015, a nurse called her to express concern about Smiley's chest pain, so she saw him again and made a progress note. (Plaintiffs Exhibit 2, p. 37.) According to Dr. Heacock, Smiley looked anxious and had an elevated heart rate, and she explained how, based upon examining him and evaluating his heart rhythm, she wanted to rule out acute coronary syndrome, a pulmonary embolism, or pleuritis. Dr. Heacock testified that she ordered a check of Smiley's troponin level, which is a marker used to identify someone at risk of having a heart attack, she ordered a chest x-ray, and she ordered a D-dimer test. The D-dimer test, Dr. Heacock explained, is a blood test that she ordered to rule out a pulmonary embolism. When the lab results came back, Dr. Heacock stated, the troponin levels were normal, suggesting that Smiley did not have acute coronary syndrome. Dr. Heacock related that the D-dimer level was elevated, however, so she ordered another test that definitively ruled out a pulmonary embolism.

         {¶14} Dr. Heacock explained that as Smiley continued to have chest pain, tachycardia, and significant anxiety symptoms, it was difficult to tell whether the symptoms were from pleuritis or were secondary to steroidal medication. Dr. Heacock noted on February 3, 2015, that she was called to see him due to reports of him having chest pain, tachycardia, and anxiety, as well as biting his arm and yelling "get them off of me, get them off." (Defendant's Exhibit B, p. 55.) Dr. Heacock stated that she arranged a psychiatric consultation, which, as she wrote in her progress notes on February 3, 2015, determined that Smiley seemed to be having a reaction to steroidal medication. (Plaintiffs Exhibit 2, p. 49.) Regarding Smiley's right knee pain, Dr. Heacock testified that due to its persistence she eventually ordered an MRI that showed a large effusion, which was significant in her view since a large amount of fluid had already been removed from the knee a few days earlier, and a ruptured Baker's cyst was found as well. (Defendant's Exhibit B, p. 105.) After having obtained what she considered to be good explanations for Smiley's symptoms, Dr. Heacock explained that on the evening of February 3, 2015, she sent an email to colleagues who would be coming on shift and replacing her wherein she identified Smiley as among several patients whom she felt could potentially be discharged the next day.

         {¶15} Dr. Heacock testified that she does not feel that she failed to diagnose a DVT because Smiley did not have the clinical symptoms of a DVT and, between the ankylosing spondylitis, the related knee issues, and consultations and testing, the symptoms that he did have were explained. Dr. Heacock acknowledged that impaired mobility is a risk factor for DVT, but she understood from Smiley that he could ambulate with a walker, and, as she described this risk factor, it is more associated with someone who is bedridden rather than ambulatory with an assistive device. Dr. Heacock acknowledged that ankylosing spondylitis is a risk factor for developing a DVT, but she distinguished having a risk factor versus having clinical symptoms.

         {¶16} Clinical symptoms of a DVT can include unilateral swelling and pain in the lower leg, starting in the calf, and tenderness to palpation of the calf, Dr. Heacock stated, but she did not find the calf to be swollen or tender. Dr. Heacock related, for instance, that on February 1, 2015, she specifically noted there was "No LEE," meaning no lower extremity edema. (Plaintiffs Exhibit 2, p. 53.) In terms of where Smiley did have swelling during his hospitalization, Dr. Heacock stated that she thought it was essentially associated with the effusion of the right knee. Dr. Heacock acknowledged that nursing notes documented some consistent swelling in the right "leg," but she stated that the software the nurses use to make their notes does not give them the ability to pinpoint where the leg is swollen, such as distinguishing between the upper and lower portions of the leg. Dr. Heacock was also asked about nursing notes documenting tenderness in the knee, ankle, and foot, and she testified that since ankylosing spondylitis typically affects joints, whereas a DVT does not, ankylosing spondylitis was consistent with those symptoms and it would not be reasonable to assume from such notes that Smiley had tenderness in the calf.

         {¶17} Regarding the test of the D-dimer level when she wanted to rule out a pulmonary embolism as a possible cause of the chest symptoms, Dr. Heacock acknowledged that an elevated D-dimer level can be consistent with a DVT, and she was questioned about whether further tests should have been ordered to determine why the D-dimer level was elevated. But, Dr. Heacock testified that the D-dimer level is not at all specific to blood clots, as it may be elevated for various reasons, and, in this case, the rheumatological inflammation that Smiley had in connection with ankylosing spondylitis provided an explanation. Indeed, Dr. Heacock stated, Smiley's lab work revealed two other elevated inflammatory markers that were consistent with that explanation. Dr. Heacock stated that since she had no clinical suspicion of a DVT with this patient, and with there being an explanation for the elevated D-dimer level, there was no need to order testing to rule out a DVT-an ultrasound being the definitive test. Dr. Heacock was asked several questions about applying the Wells Criteria, which she acknowledged calls for a D-dimer test when performing a workup on a patient who is found to have only a low risk of DVT, but her testimony was that the Wells Criteria is not indicated when there is no clinical suspicion of DVT. Dr. Heacock stated that only if she had clinical suspicion of DVT would she have applied the Wells Criteria and ordered an ultrasound once the D-dimer level was found to be elevated. Simply put, according to Dr. Heacock, a patient's clinical symptoms are used to determine whether DVT should be in the differential diagnosis, and if it is, that is when testing should be done to rule it out.

         {¶18} Alexa Meara, M.D. testified that she is board-certified in internal medicine and rheumatology and is an Assistant Professor in defendant's Department of Internal Medicine, where she sees patients, teaches, and performs research. During the timeframe at issue, Dr. Meara testified, she was a rheumatology fellow and saw patients in an outpatient clinic and performed consultations in the hospital. Looking at the medical records, Dr. Meara explained that when Dr. Matcheswalla admitted Smiley to the hospital on January 30, 2015, he ordered a rheumatology consultation. (Plaintiff's Exhibit 2, p. 91.) Dr. Meara testified that she documented performing the consultation later that day. (Defendant's Exhibit B, p. 21.) During the consultation, Dr. Meara stated, she would have given Smiley a full physical examination, and beforehand she likely read Dr. Matcheswalla's History and Physical report. Dr. Meara stated that she understood Smiley had a history of ankylosing spondylitis and came to the hospital with worsening back and leg pain. Dr. Meara explained that the rheumatology consultation was ordered essentially to determine if Smiley's symptoms were being caused by his ankylosing spondylitis.

         {¶19} As a consultant, Dr. Meara stated, her role is to perform a physical examination and make recommendations. Dr. Meara explained the findings she recorded upon examining Smiley, including a right knee effusion, meaning fluid on the knee, as well as inflammation in the knee, and that her plan was to give the knee a steroid injection and if there was no improvement in 48 hours she would recommend an MRI. From what Dr. Meara found, it appeared that Smiley was having a flare-up of ankylosing spondylitis, albeit different than his typical presentation. Pertaining to ankylosing spondylitis, Dr. Meara at the time recommended some additional medication to help with inflammation as well as physical therapy. (Defendant's Exhibit B, p. 24.) Insofar as her note indicates she called plaintiff at Smiley's request, Dr. Meara stated that it is her custom to contact patients' families.

         {¶20} The next time she saw Smiley was February 2, 2015, Dr. Meara stated. Beforehand, she would have reviewed anything in the chart that happened since she last saw him, Dr. Meara explained. Dr. Meara was asked specifically about the elevated D-dimer results from the testing ordered by Dr. Heacock, but she explained that in her field all patients have elevated inflammatory markers, so it is difficult to assign any meaning to an elevated D-dimer level and it is not a test she uses. Dr. Meara testified that asymmetrical swelling and pain are the primary signs she looks for in terms of a potential DVT, and if she were concerned, she would order an ultrasound as a diagnostic test. Dr. Meara noted during this second visit that Smiley reported the steroid injection provided some relief for the knee pain, but the pain persisted and Smiley did not want another injection because of the side effects. (Defendant's Exhibit B, p. 24.) Dr. Meara explained the findings that she recorded and she testified that she recommended an MRI of the right knee to rule out a fracture. An MRI was performed on the right knee later that day, she testified, and showed a large effusion and inflammation of the joint lining, as well as a Baker's cyst and a popliteal cyst. (Plaintiffs Exhibit 2, p. 40.) Dr. Meara related how the MRI explained Smiley's pain symptoms, consistent with ankylosing spondylitis. Dr. Meara described the plan she recommended at that time for managing the ankylosing spondylitis with medication on an outpatient basis going forward, and leaving the care of the knee and chest pain to other specialists or primary care providers. From a rheumatology standpoint, it was appropriate at that time to discharge Smiley, Dr. Meara stated.

         {¶21} Robert K. Mathew, D.O. testified by way of deposition.[1] (Joint Exhibit 1.) Dr. Mathew related that he is board-certified in internal medicine and practices as a hospitalist at Dartmouth-Hitchcock Medical Center in New Hampshire, where he is an Assistant Professor of Medicine and the On-Call Medical Director. Dr. Mathew testified that he became involved with Smiley's care when he came on shift on February 4, 2015, taking over for Dr. Heacock. Dr. Mathew explained that toward the end of her shift Dr. Heacock sent an email to him and other hospitalists to communicate about their patients, which was a standard practice. When Smiley's care was transitioned to him, Dr. Mathew stated, he would have had the information Dr. Heacock provided and he would typically review information in the patient's chart, such as the history, trends in bloodwork and vital signs, and diagnostic interventions, and in the case of prisoners, the transfer document from the prison. Dr. Mathew understood that Dr. Heacock felt Smiley's knee symptoms were being caused by an exacerbation of ankylosing spondylitis, that the knee had been tapped to rule out an infection and studied with an MRI that further explained the knee problems, and he was having chest pain and anxiety attacks likely related to steroid medication, and, if he did well after some adjustments to his medication, Dr. Heacock felt he could be discharged and get outpatient follow-up care for orthopedics, rheumatology, and physical therapy.

         {¶22} Dr. Mathew acknowledged that on some level he deferred to Dr. Heacock, and he explained how hospitalists also rely on the input of consultants in managing patient care, but he explained how he would have evaluated Smiley's condition, particularly over the last 24 hours when he came on shift, and made sure that orders for any testing or consultations were carried out and were not contrary to discharging Smiley. Dr. Mathew explained that he examined Smiley before making the decision to discharge him, and that by this point Smiley's knee effusion was tender but the knee had better range of motion than previously described, and Smiley's pain was better managed and his ambulation was slowly improving such that he was able to move with assistance. Dr. Mathew explained that he then decided to discharge Smiley and he described the plan of care upon discharge, and, he stated, nothing in the discharge notes would raise any concern for DVT. Dr. Mathew testified that had he seen signs of DVT, he would have ordered an ultrasound since it was already known that the D-dimer level was elevated. Dr. Mathew explained that whereas a D-dimer test is one way to test for a DVT, an elevated D-dimer level can result from other things than just a blood clot, so a positive test must be taken in context with the patient. Pain and swelling in a lower extremity is chiefly what Dr. Mathew looks for in terms of concern for a DVT, he stated. Immobility, trauma, malignancy, and inflammatory states are among the risk factors for DVT, according to Dr. Mathew, so in this instance the inflammatory state associated with ankylosing spondylitis was a risk factor, he stated. In Dr. Mathew's view, though, immobility was no more of a risk factor than with hospitalized patients in general.

         {¶23} Tamara Salyer testified that she has been a registered nurse for 21 years and at all times relevant was employed at Franklin Medical Center, which is operated by the Department of Rehabilitation and Correction. Salyer testified that medical records show when Smiley was discharged from the hospital on February 4, 2015, the Department of Rehabilitation and Correction transported him to Franklin Medical Center and she admitted him into the facility. During that process, Salyer stated, she would have reviewed parts of the hospital chart to familiarize herself with what transpired there. Salyer testified that warmth, tenderness, swelling, and redness are symptoms of a DVT, and if she had suspicion about a patient having a DVT she would notify an advanced level provider, meaning a doctor or nurse practitioner. In this case, Salyer recounted, she only knows what is set forth in the medical records, which show that she did not note any such suspicion or notify an advanced level provider either at the time of admission, or when she saw Smiley again on February 7, 2015. Salyer agreed that even though she was confident to rely on the professionals at the hospital to detect a DVT, it did not relieve her of the duty to examine the patient.

         {¶24} Teddi Anderson testified that she has been a registered nurse since 1989 and at all times relevant was employed at Franklin Medical Center. Anderson testified that defendant's hospital commonly prepared a discharge summary when it discharged an inmate-patient, which in this case Dr. Mathew prepared. (Plaintiffs Exhibit 3, p. 162.) While she would rely on the expertise of the professionals at the hospital in reviewing a patient's complaints, she explained, it did not relieve her from her duties in assessing the patient. Anderson testified that she understands the clinical signs of DVT to be cramping, redness, pain, and swelling, in the legs or arms, and that signs of a pulmonary embolism include shortness of breath, decreased saturation levels, pain in inspiration and expiration in the chest, as well as back pain. If she suspected either condition, Anderson stated, she would contact an advanced level provider, but there is no documentation that she had any ...

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