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If you have completed case D, this is a review. Completion of this case will not be counted toward your assignment.
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You are the acute care doctor at the Family Practice Clinic, seeing Mrs. Brown for the first time. Mrs. Brown is a 67-year-old woman with a two-day history of swelling and pain in her right lower leg. The pain worsens with walking. Before evaluating Mrs. Brown, let’s review some important information about swelling of the legs. |
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Now let’s see Mrs.
Brown. She remembers first noticing right calf pain when arising from
bed yesterday morning. She noticed the right lower leg was swollen and
red. She denies any traumatic event or recent strenuous activity. In
fact, she just returned from her winter stay in Florida, and the long
drive gave her legs a needed rest. The leg pain worsens with walking,
especially pushing off with her toes. The pain is relieved with rest and
elevation but her calf continues to hurt. She describes the pain to be
most severe “inside her calf.” She has not had this leg swelling and
pain previously and has never had leg edema. She denies fever or night
sweats. She can’t recall any reason for her skin to be infected. She
recalls no bites or scrapes to her calf area. Four months ago, Mrs.
Brown had a breast mass removed that was found to be malignant. A local
surgeon is following her and told her the nodes were cancer free and the
tumor was completely removed.
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ROS: generally is negatives, and
specifically the patient
Past Medical History:
Surgical History:
Meds:
Allergies:
Social History:
Family history:
Now that we have a complete history, let’s move on to the physical exam. Before you complete a thorough exam, we should make sure we are prepared to examine the lower extremities.
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On physical exam, Mrs. Brown is mildly
obese, alert, oriented and in NAD. She has a supple neck without
lymphadenopathy or JVD. Lungs sounds are coarse throughout bilaterally.
Her cardiac exam is normal - regular rate and rhythm, without murmurs.
Abdominal exam is benign with normoactive bowel sounds, nontender, and
no organomegaly. On inspection, the right lower extremity (RLE) appears edematous and mildly erythematous distal to the knee compared to the left. The right calf is 24 cm and the left is 20 cm. There is no skin breakdown appreciated. On palpation, the right calf is warmer and firmer than the left, and the edema is nonpitting. Superficial palpation of the right calf is nontender. There is moderate tenderness to deep palpation over the calf and popliteal vein. Femoral, popliteal, posterior tibialis, and dorsalis pedis pulses are all 2+ and equal bilaterally. Homan’s sign is not present. Sensation is intact bilaterally.
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| Before we move on to the laboratory and
diagnostic studies, let’s learn more about DVT.
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Mrs. Brown is sent to the nearby hospital for a diagnostic
duplex ultrasound of the lower extremities.
While waiting in the Emergency Department waiting room, she develops sudden chest pain and shortness of breath. She is immediately taken to a room where hand-carried records from her family physician are quickly reviewed while the nurse takes her vital signs: BP 150/96 RR 21 Pulse 99. |
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Mrs. Brown’s lab results reveal a normal CBC, lytes, PT/PTT, and
cardiac profile. However, she has an elevated d-dimer - 4026. Her CXR and EKG are as follows: CXR - Without active disease. No definite infiltrate. Possible left atelectasis. EKG - Normal Sinus Rhythm. |
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As Mrs. Brown’s lab studies are non-specific and the suspicion
for PE is high, she is sent to radiology for a Spiral Chest CT. The Chest CT demonstrates multiple pulmonary emboli bilaterally. Small pleural effusions and atelectasis are also noted. Given her initial presentation, she is now sent for a duplex ultrasound of the lower extremities to determine if a DVT was the source of her PE. The ultrasound is positive for a DVT in her right lower extremity. Mrs. Brown has a calf vein thrombi extending to the popliteal veins. No further studies are needed in this case, but for your benefit, two venogram studies follow exhibiting obvious calf vein clots. Notice the opaque blood in veins ending in lucent areas. These lucent areas are clot. The key to finding clots is to look for “railroad tracks,” representing thin streaks of blood along the walls of veins. The blood is attempting to squeeze by the clot. Unfortunately for Mrs. Brown she has a PE and DVT. The good
news is that these conditions can be effectively treated if
diagnosed and acted upon promptly. |
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