with Rick Place, Inova Fairfax, on the Hot Seat
The Case
EXAM: 37.1C, HR 84, RR 20, 98% RA, weight 122 kg
General: Appropriate for age. Cooperative.
Skin: No rash. No erythema.
Cardiovascular: Regular rate and rhythm. No murmur or gallop. Normal peripheral perfusion. Extremity pulses 2+ b/l.
Respiratory: Lungs clear to auscultation. Respirations non-labored. Breath sounds are equal. Symmetrical chest wall expansion.
Chest wall: No tenderness.
Musculoskeletal: Normal AROM/PROM. Normal strength. No deformity. Tenderness to palpation of right mid-posterior calf. No palpable cord. Difficult to appreciate edema due to patient's body habitus. Calves measure 51cm b/l. 1+ pitting edema b/l. No erythema noted.
Neurological: Alert. No focal neurological deficit observed. Normal sensory observed. Walking with limp 2/2 to right calf pain.
Lymphatics: No lymphadenopathy
Questions for you
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Come back later for the denouement of this case
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
While most of the DVT and PE literature is in adults, this adolescent is adult habitus and physiology (that is - can get pregnant - and worth checking urine-hcg right now in ED). So if you use the wells DVT critieria: http://www.mdcalc.com/wells-criteria-for-dvt/ - I score her at 2 points - 1 for tenderness and 1 for swelling of the leg (family report - they have seen these legs longer than you have and if they think one is more swollen, they are probably right - circumference measurements are challenging on obese legs). This puts her in the moderate risk category so she needs an ultrasound for DVT, I would get it of the entire leg in case she has a more proximal clot. D-dimer not helpful since pre-test probably already high enough. If negative, first talk with the ultrasonographer to assess whether they were adequately able to see the entire vasculature and that the attending reviewed the images as well; if still negative, get an xray to r/o bone tumor.
ReplyDeleteAnother scenario: IF she did not have the swelling, and IF she only had tenderness, and IF she only had symptoms for 1-2 days, and IF you were in a low resource setting without ultrasound, she would score 1 point (low risk) and you could consider starting with a d-dimer (if negative - send home with instructions to f/u if not resolving or PE signs; if positive - refer elsewhere for u/s).
Going outside in:
ReplyDelete- skin: the pain is not coming from the skin, as there is no bruising/ erythema/ swelling to indicate trauma or infection.
- muscle: myositis (viral, exertional) is typically bilateral. Trauma to the calf muscles can be very painful and surprisingly long-lasting (weeks). But painful trauma is usually seen in athletes, especially football and soccer, where a lot of kicking of other people occurs. So need to ask about trauma. Infection, specifically with GAS> Staph, is the most serious concern- necrotizing fasciitis or a more localized abscess. The hallmark of nec fasc is pain out of proportion to findings at the skin surface. There are no skin changes or fever, and the pain does not sound severe, so this is reassuring. But this could still be an infection in evolution.
- vessels: a thrombus is the most likely vascular abnormality. Her only risk factor for a DVT is obesity and therefore possible sedentary lifestyle. But she hasn't been completely immobilized. Also, check her for pregnancy (incr coagulable state).
- bone: osteo is always possible, but probably not my first concern, since her pain is in her calf. Osteogenic sarcoma of proximal tibia is a consideration.
So, plain films to look for lytic lesions or the sunburst pattern of osterogenic sarcoma. Highest yield test will probably be an ultrasound, to look for a fluid collection- blood or pus. Duplex scan will need to be done since a DVT has the risk of extension and embolization. Labs: CBC, ESR, CRP, coags, BCx only if antibiotics are given for any reason.
I love the way Jen broke this down by tissue origin ! Translating that into a clinical approach, what i do is:
ReplyDelete1) r/o DVT. Of course we're all going to do an US, so a D-dimer doesn't add anything here.
2) do labs for hypercoagulable (in case it's a DVT) and add CK and CBC/CRP to point towards potential infectious or muscle etiology
3) do XR to exclude bony origin
4) repeat clinical exam..........everything else (soft tissue tumor, cyst, hematoma, phlebitis, etc) should be differentiated on physical exam to dictate further workup. all of this can be followed out-patient.
So.... what if this patient was presenting in a clinical environment without immediately available ultrasound (for those of us at CNMC-- if this patient was presenting at our UMC campus): would that influence your workup? I.e. would a D-dimer help you decide whether or not to transfer her to a site with immediately available ultrasound? Or is your level of concern for DVT so high that you would transfer regardless (as Dave said: "Of course we'll all do an US")?
ReplyDeleteThis may be totally off base - but I think you have to consider more systemic problems here. Why does a 14yo F have 1+ pitting edema bilaterally? She's too young for true venous stasis. Is her heart functioning? Her kidneys? Is her albumin zero? Or is this an inaccuracy in our physical exam and this is actually non-pitting edema?
ReplyDeleteThe other thing to think about is that the Well's Criteria is really used for patients in which DVT/PE is high on the differential. Those patients are already stratified to "likely to have a DVT/PE". This patient is not in that population. This is a patient who is "unlikely to have a DVT", or "low suspicion", so something like the PERC criteria may be more appropriate here. The PERC criteria are:
No Hypoxia — SaO2 >95%
No unilateral leg swelling
No hemoptysis
No prior DVT or PE
No recent surgery or trauma
Age <50
No hormone use
No tachycardia
Patients that meet ALL of the PERC criteria do not need further testing/imaging to eval for DVT or PE (ie. no d-dimer, no ultrasound, no PE protocol CT or VQ scan).
Do remember that both Well's and PERC were created in the adult population - and risk factors for pediatric DVTs/PEs are different than those in adults, but it's still worth thinking about.
I would approach this patient with the primary intent of answering the question: what can I not afford to miss on this patient...on this visit.
ReplyDeleteLike many problems in medicine, the etiology could be something you simply can't prove, like a strained muscle (which is clearly not the case here, as it might be in real life). So testing must be directed at eliminating things that you CAN identify, things that are of relatively immediate clinical importance. The most obvious question is whether this patient has a DVT. As noted, the patient has no known risk factors, although some (adolescent) studies suggest that obesity may be a minor risk factor.
One approach when deciding whether to pursue further evaluation is to use the Well's criteria. Decision aids can be useful, but only when applied to the right patient. For instance, when deciding whether to send a d-dimer to identify (or rather to exclude) PE, I will rely on the PERC rule. But the PERC rule should ONLY be used in patients with a low pretest probability. Otherwise it is invalid. Similarly, I am more likely to use the Well's criteria to exclude further evaluation rather than help me to decide whether to drive further workup. In other words, if my pretest probability is reasonably low, and I do not want to image a patient or get stuck with a false positive test (i.e. d-dimer), I will use the decision rule to justify my medical decision-making (in case I am wrong). This may not be exactly how the Well's criteria is intended, but this is how I would use it.
(There is not room here for a complete discussion of decision rules, but many rules are subjective enough from the start that you can get the answer you want simply by interpreting the data the way you want. For instance, in a prior comment the patient is scored as 2, with one for tenderness and one for swelling. I would score the patient as zero. The swelling is not confined to the affected leg and the tenderness is not specifically localized to the deep venous system). My point is that I use decision aids as a guide, not a rule. In this case, I score the patient at zero but still believe the patient is at reasonable risk of DVT.
In this case, the patient has no clear alternative reason for calf pain, and a "low probability" Well's score still gives you a 3% probability; I would not say that my concern for DVT is exceptionally low. Furthermore, exam is of very limited utility in this patient, forcing us to rely even more heavily on diagnostic testing to sort this out.
If I had 24/7 ultrasound or unlimited resources (e.g. at Fairfax), I would probably go straight to doppler ultrasound to evaluate this patient. It may answer the question positively, or if not, may provide additional information, such as an abscess, hematoma, soft tissue mass, or Baker's cyst (in adults). (Incidentally, in Invercargill, after hours, we would risk stratify the patient and give a shot of enoxaparin and bring them back the next day for a sonogram. If they risk stratified low, I might still bring them back but pass on the LMWH).
I would also order a d-dimer on this patient as ultrasound has good but limited sensitivity for calf DVT (particularly in an obese patient). It is extremely good for proximal venous thrombosis but less sensitive for distal clots (the diagnosis of interest here). If the Doppler was negative (i.e. for proximal DVT), one would need to consider a repeat sonogram in a week or two as 30% of distal DVTs will migrate proximally. One advantage of a negative doppler AND a negative d-dimer is that the need for a follow up ultrasound is probably unnecessary.
Finally, since this patient could have practically anything (especially given that she is a hot seat patient) and since exam is so incredibly limiting, I would likely expand my workup to include screening labs for inflammatory markers (CBC/CRP) which might help suggest a myositis or osteomyelitits and an Xray to exclude occult fracture, some weird bony problem like malignancy or bone cyst (less likely given the calf pain).