Name: Alan Jones

Section/group number: IMD 18 batch 5

Date: December 8, 2021
Email number: alan34jones@gmail.com

PART 1

Salient features:

History
1. 79 Year old bed ridden female
2. 3 days pta - left calf circumference has increased
3. 1 hour pta - shortness of breathe with persistence of left calf muscle swelling

Past medical history

1. history of breast cancer (stage 2 underwent chemotherapy and radiotherapy)
2. 4 years ago she had ischemic stroke
3. Hypertension

Family history
1. mother had breast cancer and hypertension

Personal and social history

1. history of smoking - 20 pack years

Physical examination
1. vitals - BP 100/70mmHg
R.R 20 cpm
H.R 115 bpm
Temperature 36 degrees Celsius
02 sat 90
2. PMI at the 6th intercostal space
3. tachycardia was noted
4. left calf measured 7 cm in diameter with tenderness on palpation of mid calf
5. right calf measured 4 cm in diameter
6. left dorsalis and posterior tibialis pulse was grade 1
7. right dorsalis and posterior tibilalis pulse was grade 2
8. there was pitting edema grade 2 on the left leg.
Initial impression
PULMONARY EMBOLISM SECONDARY TO DEEP VEIN THROMBOSIS

I feel this is so, because the patient is 79 years old which is on the older side which
is a risk factor and also adding to the fact that the patient is bed ridden for the past
4 years, previous history of breast cancer - which are also prominent risk factors
and they lead me to consider DVT.
It must also be noted that the presentation of the patient is with shortness of breathe
along with persistent left calf swelling which started 3 days ago, which indicate
some issue with blood clot in the leg and that mixed with breathless indicate some
pathology with the lungs.
Furthermore, the physical examination seems to be in support of the above said
impression - the tachycardia (which indicates there is blood leakage and the heart
compensates by beating faster), the swelling of the left calf muscle which is 3cm
wider than the right, the difference in the grades of the pulse and along with the
pitting edema of grade 2 indicate that there is blood pooling in the left calf, which
due to gravity is causing the edema, i.e, it is a delayed complication of DVT that
causes venous valve in the leg to be incompetent and exudes interstitial fluids.
Therefore all these point to the bleeding which Is in the left calf and also the fact
that she is hypertensive, a previous smoker is also more in support.

Diagnostic test

1. wells DVT Score and Wells PE score - it is expected to find a dvt score 3 or
greater than 3, and PE score 4 or greater than 4.

(for our patient the WELLS DVT SCORE IS 4, AND PE SCORE IS 9)

2. D DIMER if wells test is -ve.

3. Chest x ray - should show wedge shaped infarct (rare) but is important to rule
out other conditions
4. ECG - sinus tachycardia should be seen
5. ABG - DECREASED 02, decreased CO2. Increased Ph

Differential diagnosis

1. congestive heart failure

Rule in - the following are the factors which made me to consider the above
diagnosis - patient is 79 years old with a history of diabetes and hypertension. Her
PMI was found at the 6th intercoastal space instead of the 5th intercoastal space,
which indicated a problem in the left ventricle (left ventricular hypertrophy),
shortness of breath. History of ischemic stroke

Rule out - the edema is unilateral and not bilateral. This means there is a localized
problem rather than a systemic one. Also, the wells score for DVT seems to be
+ve.

Diagnostic test
1. ECG - we expect to find axis deviation
2. BNP - ELEVATED
3. Kidney fuction test - elevated levels of creatinine
4. CXR - cardiomegaly and pulmonary edema/

2. cellulitis

Rule in - unilateral edema and swelling of calf

Rule out - patient does not have fever, or dyspnea or lesions.

Diagnostic - cbc will show increased wbc levels and increased CRP

3. Pulmonary edema secondary renal failure

Rule in - the patient has shortness of breath, edema, tachycardia.

Rule out - does not explain the unilateral edema, the positive wells score and the
history of the patient,

Diagnostic test - chest x ray should reveal effusion in the affected lung
Kidney function test should have elevated creatinine
Blood urine nitrogen should be elevated.