by Joelle Simpson with Shilpa Patel on the Hot Seat
It’s 5pm on a weekday just before Thanksgiving and the Adult ER resident picks up the chart for the following patient:
CC: Limp, Leg swelling
HPI: 12yo female with right lower extremity swelling (shin and calf) and pain x 2 weeks. She has had difficulty bearing weight. Walks with a limp now and presents because it is getting worse and mom more clearly notices the swelling. Over the counter pain medications have helped a little.
ROS: denies fever, denies trauma, denies systemic disease.
EXAM: Vital Signs: Age appropriate
Pertinent positives:
The RLE is slightly swollen from knee to ankle, strong DP and PT pulses. There is a palpable knot in the deep mid-calf. + Tenderness to palpation throughout without warmth or erythema. Skin does seem more taut than contralateral leg. Able to fully range R hip/ankle and knee.
Pertinent negatives:
No warmth, erythema, fluctuance, induration, ecchymosis, skin color changes. No knee effusion or tenderness to palpation
Rest of exam: Unremarkable
Medications: None
PMHx: Unremarkable
Fam Hx: Negative for bleeding or clotting disorders, Unremarkable
Differential from the resident: “I think this could be a DVT – we see these in the Adult ER – I want an ultrasound”
You decide to add a CBC, ESR, Coags, CRP, CK and X-ray to his orders and have the following results
X-ray: No bony abnormality, soft tissue effusion or calcifications.
US Doppler: Neg for DVT but notes heterogeneous mass in deep muscle most consistent with clot
Labs: CBC – unremarkable, CMP – unremarkable, Coags - normal, CK – normal, ESR 90 and CRP 1.7
Questions for you (click on "vote" to see what others said):
The nurse comes to you and says mom has expressed a preference to go home and return if nothing else is to be done tonight. You plan to speak to the PMD to assure follow-up and further evaluation.
What do you think? Add your comments below by clicking on "comments." Easiest if logged into your gmail account but you can do it without as well. Come back later for the Hot Seat response by Shilpa Patel and case denouement.
It’s 5pm on a weekday just before Thanksgiving and the Adult ER resident picks up the chart for the following patient:
CC: Limp, Leg swelling
HPI: 12yo female with right lower extremity swelling (shin and calf) and pain x 2 weeks. She has had difficulty bearing weight. Walks with a limp now and presents because it is getting worse and mom more clearly notices the swelling. Over the counter pain medications have helped a little.
ROS: denies fever, denies trauma, denies systemic disease.
EXAM: Vital Signs: Age appropriate
Pertinent positives:
The RLE is slightly swollen from knee to ankle, strong DP and PT pulses. There is a palpable knot in the deep mid-calf. + Tenderness to palpation throughout without warmth or erythema. Skin does seem more taut than contralateral leg. Able to fully range R hip/ankle and knee.
Pertinent negatives:
No warmth, erythema, fluctuance, induration, ecchymosis, skin color changes. No knee effusion or tenderness to palpation
Rest of exam: Unremarkable
Medications: None
PMHx: Unremarkable
Fam Hx: Negative for bleeding or clotting disorders, Unremarkable
Differential from the resident: “I think this could be a DVT – we see these in the Adult ER – I want an ultrasound”
You decide to add a CBC, ESR, Coags, CRP, CK and X-ray to his orders and have the following results
X-ray: No bony abnormality, soft tissue effusion or calcifications.
US Doppler: Neg for DVT but notes heterogeneous mass in deep muscle most consistent with clot
Labs: CBC – unremarkable, CMP – unremarkable, Coags - normal, CK – normal, ESR 90 and CRP 1.7
Questions for you (click on "vote" to see what others said):
The nurse comes to you and says mom has expressed a preference to go home and return if nothing else is to be done tonight. You plan to speak to the PMD to assure follow-up and further evaluation.
What do you think? Add your comments below by clicking on "comments." Easiest if logged into your gmail account but you can do it without as well. Come back later for the Hot Seat response by Shilpa Patel and case denouement.
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