mdebord Posted June 13, 2013 Share Posted June 13, 2013 Hello! I have a new case for y'all. It's not very complicated, but there are some important take-home points. 51yo obese white female with PMHx of menorrhagia and anemia x 1 year (followed by GYN) and DVT of right cephalic vein 9m ago treated with coumadin x 3m presents to Family Practice with "knot on back of leg." Where do you start? (Remember to go in order:HPI/histories, ROS, PE, etc. before ordering any tests). Link to comment Share on other sites More sharing options...
winterallsummer Posted June 13, 2013 Share Posted June 13, 2013 Sounds like baker's cyst. H&P for arthritis (joint pain, med use, stiffness, etc). Link to comment Share on other sites More sharing options...
mdebord Posted June 13, 2013 Author Share Posted June 13, 2013 Ok, pt denies joint pain or stiffness, no known h/o arthritis. She does admit to some "tightness" in the left leg (where the knot is) when walking. Only medication is occasional Provera for the menstrual bleeds (last course was a few months ago). Link to comment Share on other sites More sharing options...
loliz Posted June 13, 2013 Share Posted June 13, 2013 Where is the knot? Back of thigh/calf/knee? When did it start? Is it painful? Has it happened before? Any trauma, bruising, itching, erythema? Link to comment Share on other sites More sharing options...
mdebord Posted June 13, 2013 Author Share Posted June 13, 2013 Knot is at the posterior calf, started acutely 5 days ago and stable since. Exacerbated by walking, she has not taken anything to attempt to relieve it. No trauma, bruising, itching, or erythema/warmth. When asked about what she did last week, pt reports flying for 3 hours on Thursday and 3 hours on Friday shortly before symptoms started. Ok, let's have any other questions y'all want to ask and start to form a differential. We already have Baker's cyst. I'll be gone to a meeting for a few hours, so hopefully some others will have time to join in. Link to comment Share on other sites More sharing options...
PYRITE Posted June 13, 2013 Share Posted June 13, 2013 Fever? Chills? Fatigue? Change in weight or appetite? Change in diet? Any leg cramps? Varicose veins? Edema? maybe another DVT Link to comment Share on other sites More sharing options...
Jorge Posted June 13, 2013 Share Posted June 13, 2013 Yea, the long flights before the sx started is concerning for another DVT Link to comment Share on other sites More sharing options...
winterallsummer Posted June 14, 2013 Share Posted June 14, 2013 DDx: Baker's cyst DVT Thrombophlebitis Burst cyst Link to comment Share on other sites More sharing options...
bgdog Posted June 14, 2013 Share Posted June 14, 2013 Sounds like baker's cyst. H&P for arthritis (joint pain, med use, stiffness, etc). Really, with a hx of dvt and on Coumadin? That's your first thought? Link to comment Share on other sites More sharing options...
mdebord Posted June 14, 2013 Author Share Posted June 14, 2013 Fever? Chills? Fatigue? Change in weight or appetite? Change in diet?Any leg cramps? Varicose veins? Edema? maybe another DVT Ok guys, good job; time for ROS. GEN: Denies fever, chills, fatigue, recent illness. CV: Admits to "heart beating a little fast." Denies chest pain, palps, lower extremity edema, varicose veins. Resp: Admits to DOE for the past 5 days. Denies cough. GI: Denies N/V/D/C, weight loss, change in appetite. MSK: See HPI. VS: BP 114/76, HR 96, RR 16, O2 100% on RA, T 98.6. Any new thoughts after that information? What will you be looking for on physical exam? Link to comment Share on other sites More sharing options...
loliz Posted June 14, 2013 Share Posted June 14, 2013 Check pulses everywhere, look for edema, check lower extremity sensation, listen to lungs and heart Link to comment Share on other sites More sharing options...
GatorRRT Posted June 14, 2013 Share Posted June 14, 2013 Perhaps perform a homan's test? With the Hx of DOE x 5 days and complaints of tachycardia; I'm concerned about a potential PE. Link to comment Share on other sites More sharing options...
tigerlily Posted June 14, 2013 Share Posted June 14, 2013 Ok guys, good job; time for ROS.GEN: Denies fever, chills, fatigue, recent illness. CV: Admits to "heart beating a little fast." Denies chest pain, palps, lower extremity edema, varicose veins. Resp: Admits to DOE for the past 5 days. Denies cough. GI: Denies N/V/D/C, weight loss, change in appetite. MSK: See HPI. VS: BP 114/76, HR 96, RR 16, O2 100% on RA, T 98.6. Any new thoughts after that information? What will you be looking for on physical exam? With that h&p, I would say it is psychosomatic. Ultrasound to rule out DVT? Link to comment Share on other sites More sharing options...
tigerlily Posted June 14, 2013 Share Posted June 14, 2013 I didn't think we should be doing homan's test, I heard it could dislodge a thrombus? Link to comment Share on other sites More sharing options...
mdebord Posted June 14, 2013 Author Share Posted June 14, 2013 Perhaps perform a homan's test? With the Hx of DOE x 5 days and complaints of tachycardia; I'm concerned about a potential PE. Ding ding ding! So yes, Homan's is controversial. I did do it, and I'll say it was equivocal (hurt her a little, but I wasn't impressed). So, for the PE: GEN: Obese white female in no acute distress. HEENT: PERRL. Mucus membranes moist. Oropharynx clear. CV: RRR, no m/r/g. Upper and lower extremity pulses 2+ and symmetric. Cap refill <2sec. No lower extremity edema or tortuous veins. Resp: CTAB. MSK: There is an approximately 3cm x 4cm poorly-defined swelling to the proximal posterior calf. No overlying skin changes (no erythema, warmth, bruising). Mildly TTP, no fluctuance. Exam is limited by pt's body habitus. Skin: pallor throughout Psych: Nl mood and affect, appropriate insight. Now, for the million dollar question: It is 4:50 in the afternoon in my Family practice clinic. With this history and physical, what do you do? A) Send her home. B) Send her to the ER. C) Order labs/imaging and have her f/u pending results. D) other? Link to comment Share on other sites More sharing options...
loliz Posted June 14, 2013 Share Posted June 14, 2013 Considering acute onset, hx of DVT, onset after multiple flights.... probably not a good idea to send her home. Any chance you have access to duplex ultrasound at the office or a place that is open past 5? I hesitate to say ER, but I would rather be wrong than have my patient dead or more sick than when she met me! Off to bed, good luck all! Link to comment Share on other sites More sharing options...
mdebord Posted June 14, 2013 Author Share Posted June 14, 2013 So this is the big judgement call in the case. We don't have anything in-house. Had it been earlier in the day, I would have ordered a STAT Doppler at the hospital and managed her myself when I got the results. But this is one of the limitations of family practice - to get her worked up at that time of day I had to send her to the ER. Ok, so let's all move over and pretend we're now ER PAs (I have all the results by now anyway). What all do you want to order? Link to comment Share on other sites More sharing options...
PYRITE Posted June 14, 2013 Share Posted June 14, 2013 ultrasound has been mentioned, I would start there Link to comment Share on other sites More sharing options...
GatorRRT Posted June 14, 2013 Share Posted June 14, 2013 D dimer, v/q Link to comment Share on other sites More sharing options...
mdebord Posted June 14, 2013 Author Share Posted June 14, 2013 Any other labs we need? Why/why not? Link to comment Share on other sites More sharing options...
winterallsummer Posted June 14, 2013 Share Posted June 14, 2013 CBC, coags (PT/PTT), would skip D Dimer and go to US. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted June 14, 2013 Moderator Share Posted June 14, 2013 D dimer, v/q I know it's mdebord's teaching case, but I'm gonna jump in here. Why would you get these? Link to comment Share on other sites More sharing options...
GatorRRT Posted June 14, 2013 Share Posted June 14, 2013 HX of DOE x 5 days, hx tachycardia, hx of previous DVT and what in guessing is a moderate probability wells PE score (based on provided information) makes me want to r/o a PE. Link to comment Share on other sites More sharing options...
GatorRRT Posted June 14, 2013 Share Posted June 14, 2013 On further thought, no need for the d dimer since we're doing the ultrasound, and we could go with a CT chest instead of a v/q Link to comment Share on other sites More sharing options...
JoelleK Posted June 14, 2013 Share Posted June 14, 2013 With her description of heart racing was an EKG done to r/o AFib? This would increase possibility of DVT as well. U/S or Doppler, Spiral CT to r/o PE, EKG to r/o AFib. Labs - I agree w/ above PT/PTT, D-Dimer (couldn't hurt), CBC Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.