Superficial Venous Thrombosis

ID: 36y/o healthy female, came in with Lt leg pain. 

HPI: Sudden onset of pain, Lt leg 5/7, constant, stabbing, no swelling; no SOB; no cough/hemoptysis; no CP; no fever/chills; does not interfere with mobilization; no recent trauma/surgery; no IVDU; 

PMH: Endometriosis on Cyclomen (danazol) ✗ 2yr; no Hx of DVT, PE, clotting disorders; 

FH: noncontributory.

E/O: A+O ✗ 3 - NAD - ⊘ill/toxic

BP: 118/76 P: 86  R: 18  SAT: 98% RA  T: 36.7 ℃

Significant localized tenderness on the upper anteromedial aspect of the Lt leg; equal leg circumference on both sides;  no colour changes, Lt leg not warmer than the contralateral side; no calf tenderness; dorsalis pedis/pos. tibial pulses symmetrical; capillary refill normal.

CVS, Resp, Abdo exams unremarkable.

CBCD, Rapid Metabolic Panel (RMP), INR, all Ⓝ

U/S ➜ 2cm clot in the saphenous vein; no DVT; 

I/P: 36 y/o healthy ♀ with superficial venous thrombosis (SVT) precipitated by danazol. 

Stop danazol; pain management (warm/cold compress, elevation, compression stockings, NSAIDs); discuss pros and cons of NSAIDs alone vs full anticoagulation ✗ 4wk; F/U with GP in 7-10 days; discharge home with F/U precautions;   

Discussion ⁽¹⁾: 

Increased risk of thromboembolism if, ≤5cm from the saphenofemoral/saphenopopliteal junction (deep venous system), thrombus ≥5cm in length, +ve medical risk factors for DVT; These patients may benefit from anticoagulation (Rx decision should be individualized); otherwise Rx with NSAIDs, pressure stockings, elevation, warm/cold compress.

Optimum agent,dose, duration unclear; fondaparinux, UFH, LMWH, and warfarin all effective and can be used.

Repeat U/S may be necessary based on physical exam and physician’s discretion.

Remember DVT can occur in the ipsi- or contralateral lower limb in patients with SVT. 

Reference: 

1. http://www.uptodate.com/contents/superficial-thrombophlebitis-of-the-lower-extremity?source=preview&anchor=H20&selectedTitle=1~54#H20

Polyarticular arthritis

ID: 67y/o ♀, multiple medical comorbidities, brought in by EMS due to inability to walk due to joint pain. 

HPI: Hx of a mechanical fall one week ago; no ↓LOC; no head trauma; gradual onset of pain, erythema, warmth, and swelling in multiple large joints (Rt elbow and knee, Lt wrist) past 2/7. Lost ROM in the involved joints due to sever pain; unable to mobilize; no fever/chills; ROS otherwise noncontributory. 

PMH: gouty arthritis 1-2 attacks/yr on allopurinol; always Lt 1st MTP joint; last episode 2mo ago; CKD eGFR=35; stable angina on medical Rx; controlled HTN; 

E/O: A+O ✗ 3 - NAD - ⊘ill/toxic

VSSA

HEENT: no oral mucosal ulcerations; pupils 3mm symmetric, reactive, ⊘RAPD

MSK: Rt elbow, Rt knee, Lt wrist: erythematous, swollen, warm, extremely tender to touch; no active/passive ROM due to severe pain; 

The rest of the exam noncontributory. 

I/P: 67 y/o ♀ with gouty arthritis involving multiple joints precipitated by recent blunt trauma.

CBC, rapid metabolic panel (RMP), INR, serum uric acid (sUA), ESR; X ray involved joints; medicine/rheumatology consult regarding admission;  Rx as acute gouty arthritis with prednisone 50mg PO daily taper to a total course of 7d;

Discussion; 

Acute gouty arthritis can be precipitated by trauma, fatty foods, beer and spirits (NOT wine), dehydration, starvation, low-dose aspirin.

Always consider the possibility of septic arthritis, even in pt with long-standing Hx of gout. Septic and gouty arthritis can occur simultaneously in a joint.  

Release of cytokines may cause lower sUA during an attack. For most accurate sUA measurements, wait at least 2wk after complete resolution of Sx⁽¹⁾. 

Reference: 

http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gout?source=preview&anchor=H7&selectedTitle=1~150#H7