A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.

A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.

 Additional Questions

1. Do you have any medical history of peripheral vascular disease? To assess for the risk factor of Deep vein thrombosis (DVT).
2. Have you ambulated since the surgery? Lack of ambulation after surgery is a major risk factor for DVT due to venous stasis (Kruger et al., 2019).
3. Do you have a history of cardiac diseases? Cardiac diseases are a risk factor for DVT.
4. Do you use contraceptive pills, or have you taken them in the past month? Hormonal contraceptive pills are a risk factor for DVT.

Physical Exam and Further Tests

Physical exam would include an abdominal and lower limbs examination. The abdominal exam will identify any complications of the abdominal surgery, including hypo/hyperactive bowel sounds, tenderness, masses, and organomegaly. The lower limbs exam will center on eliciting the Homans sign by dorsiflexing the foot with the knee straight. The patient will be assessed for calf pain, a positive Homans sign that suggests DVT (Kruger et al., 2019). Further tests will include Ultrasonography of the left leg to assess for thrombi by directly visualizing the venous lining and looking for abnormal vein compressibility.

Subjective:

Pertinent positives: Unilateral leg edema, leg pain, tenderness, warmth on touch, and erythema over the skin.

Pertinent negatives: Bilateral leg pain, swelling, and tenderness.

Objective:

Pertinent positives: Calf pain on foot dorsiflexion (Homans sign); Uneven discoloration of the lower extremity; Difference in the circumference of the two calves more than 3 cm; Dilated collateral superficial veins; Pitting edema that is greater in the affected extremity; A palpable, indurated, cordlike, tender subcutaneous venous segment.

Pertinent negatives:  Bilateral leg tenderness and swelling; Fever.

Assessment: Differential Diagnoses

Deep Vein Thrombosis (DVT): DVT is characterized by blood clotting in a deep vein of a limb (calf or thigh) or the pelvis. Clinical manifestations of DVT include edema, tenderness, leg pain, warmth, and erythema of the skin over the thrombosis area. The more specific physical findings of DVT include calf tenderness, swelling of the whole leg, a difference in circumference between calves greater than 3 cm, pitting edema, and collateral superficial veins (Kruger et al., 2019). DVT is the presumptive diagnosis based on the patient’s positive symptoms of left calf pain, swelling, warmth, and tenderness.

Cellulitis: Cellulitis is an acute bacterial infection of the skin and subcutaneous tissue. Local symptoms of cellulitis are typically unilateral. Findings include pain, fast-spreading erythema, tenderness, and edema. The skin is usually red and edematous, and the borders are indistinct. Severe infections present with increasing pain, hypotension, tachycardia, fever, chills, headache, and delirium (Sullivan & de Barra, 2018). Cellulitis is a differential based on positive symptoms of leg pain, swelling, and tenderness.

Superficial Thrombophlebitis: This is an inflammatory-thrombotic disorder whereby a thrombus develops in a vein close to the skin surface. It is characterized by a gradual onset of localized tenderness on the affected limb, followed by an area of erythema along the direction of a superficial vein (de Almeida et al., 2019). It is a differential diagnosis based on the patient’s symptoms of localized tenderness on the left calf.

ORDER A PLAGIARISM FREE-PAPER HERE

Plan:

Pharmacological: Enoxaprin 80 mg/0.8 ml SC twice daily for 7 days (administer same time every day).

Start Warfarin 5mg oral once daily within 48 hours after administration of injectable heparin.

The reason for this treatment approach is that when initiating warfarin, it takes about five days to achieve a therapeutic effect. Therefore, there is a need to overlap warfarin intake with rapidly acting heparin for 5 to 7 days (Stevens et al., 2019).

Diagnostics: A D-Dimer test will assess D-Dimer levels which are usually elevated in DVT.

Health education and lifestyle changes: The patient will be recommended to be elevating her legs supported by a pillow or other soft surfaces when inactive (Stevens et al., 2019). She will be advised to be physically active as much as she can tolerate.

Preventive care: Early mobilization after surgery. Leg elevation

Follow-up: The patient will be followed-up after two days to check INR and re-adjust the warfarin dose according to INR results. The aim will be to maintain the INR at 2.0-3.0 (Kruger et al., 2019).

Reflection

This course has equipped me with immense knowledge in conducting patient assessments, making differential diagnoses, and developing treatment plans. My strengths included taking a comprehensive patient history and head-to-toe physical exam and identifying the most appropriate diagnostic tests to help rule out or confirm differential diagnoses. However, I encountered challenges in coming up with differential diagnoses and identifying the primary diagnoses. Besides, I had difficulties in writing drug dosages and frequency. I learned that the patient history is the most crucial element, and thus a clinician should focus on taking a detailed history. I gained new clinical skills, including performing various diagnostic tests and using diagnostic reasoning.

References

de Almeida, M. J., Guillaumon, A. T., Miquelin, D., Joviliano, E. E., Hafner, L., Sobreira, M. L., Geiger, M. A., Moura, R., Raymundo, S., & Yoshida, W. B. (2019). Guidelines for superficial venous thrombosis. Jornal vascular brasileiro, 18, e20180105. https://doi.org/10.1590/1677-5449.180105

Kruger, P. C., Eikelboom, J. W., Douketis, J. D., & Hankey, G. J. (2019). Deep vein thrombosis: update on diagnosis and management. The Medical Journal of Australia, 210(11), 516–524. https://doi.org/10.5694/mja2.50201

Stevens, H., Tran, H., & Gibbs, H. (2019). Venous thromboembolism: current management. Australian prescriber, 42(4), 123–126. https://doi.org/10.18773/austprescr.2019.039

Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical medicine (London, England), 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160

ORDER A PLAGIARISM FREE-PAPER HERE

1. A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
2. Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
3. In SOAP format, list:
Pertinent positive and negative information
(Murphy sign and right upper quadrant tenderness)
Homans’s sigh-Calf pain at dorsiflexion of the foot which is associated thrombosis.
Ultrasound test
Differential and working diagnosis
Treatment plan, including pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
• Reflect on what you’ve learned in this course:
o What were your strengths in this course?
o What was challenging?
o What new learning or insight was developed?
o What new clinical skills have you gained?