General

Weekend case discussion

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24 Jul 2016 - General
 

30 years old lady, B/G intravenous drug user, alcohol dependancy, on methadone programme, was admitted to hospital due to pain, erythematous and increasing in the swelling of left leg, with spike of temperature in a few occasions. She deny any plureritic chest pain, no shortness of breath, no productive cough, no urinary symptoms, no abdominal pain, and no headahce. On examitaion, her temperature was 37.5 celcius, left calf measure was 3.5cm larger than the right calf, with erythematous, tenderness, and increased in warmness at the skin area. Cardiovascular examination was normal with no murmur, respiratory, abdominal and respiratory examination was normal. Blood investigation showed elevated white cell count, neutrophil and CRP. What is/are your working diagnosis or differential diagnosis? What the investigations and management plan?? 


@Jennifer Winter, yes D-Dimer is always the tricky test. When we suspect patient has pulmonary embolism (PE) or deep vein thrombosis (DVT), then it will be PE or DVT unless proven otherwise by the scan. The frustration was that a lot of patients who was referred to medical admission for a variety of reasons have their D-Dimer done, and the interpretation can be difficult. For example, what will you do if a 70 years old gentleman, with proven pneumonia on chest x-ray, with spike of temperat...
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@Jennifer Winter, yes some may order for ESR and D-Dimer tests. In this case, in the settling of elevated CRP, ordering ESR (which will give the same clinical information) will be unnecessary. D-dimer will be an interesting discussion point, a lot of people will like to request for D-dimer. But, in this case, the index of suspicion for deep vein thrombosis (DVT) is very high, and we are going to treat the patient with low molecular weight heparin and perform a Doppler u/s of the left leg to rule...
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@Jennifer Winter, spot on for both cellulitis and deep vein thrombosis. Thanks. I was educated through the system of problem based learning concept, felt that learning or discussing about medicine through a case study will be the perfect way to help us to continue to improve our clinical acumen , and keep up-date with latest evidence, guideline and management strategy of specific condition. We can also see what are other people’s approaches and opinions in handling the similar case. I hope that...
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Yes, the working diagnosis will be both deep vein thrombosis with superimposed cellutitis. There were no toes cyanosis, liveeo recticularis and her dorsalis pedis pulse was good. She was not injecting into the groin. She has the left leg Doppler ultrasound scan which confirmed the diagnosis of deep vein thrombosis, and was given low molecular weight heparin (tinzaparin/enoxaparin). Iv flucloxacillin was given for her infection. Blood culture was taken prior to antibiotic treatment. Other ...
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My working diagnosis is cellulitis. My differential diagnosis is deep vein thrombosis. Does she inject into her groin ? I will check the groin for femoral artery pseudoaneurysm or injection marks. Has do got any sign of infective endocarditis as it this case, I am concern about septic emboli as well given her history. Has she got any toes cyanosis, liveeo recticularis and dorsalis pedis pulse. I will start her on IV crystalline penicillin and IV cloxacillin. Send her also for a venous ultrasoun...
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