Sign-in to Ask A Doctor - 24x7
OR
Sign in with Google
I Have To Come Up With A Soap Noted Based
Question: I have to come up with a soap noted based on these case study. I am thinking the working diagnosis should be Cellulitis,
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.
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.
Brief Answer:
Deep vein thrombosis...
Detailed Answer:
Hi,
Purely based on the history, I would first go with provisional diagnosis of deep vein thrombosis. Painfully swollen calf with tenderness after a surgery are strong indicators to it. Yes, cellulitis is also likely; but given that the complaints are sudden and there is no history of fever yet, I'd go with deep vein thrombosis.
Clinical examination followed by tests - blood counts as well as D-dimer tests would help us arrive at the diagnosis.
Hope you agree. Let me know if you need to discuss further.
Regards
Deep vein thrombosis...
Detailed Answer:
Hi,
Purely based on the history, I would first go with provisional diagnosis of deep vein thrombosis. Painfully swollen calf with tenderness after a surgery are strong indicators to it. Yes, cellulitis is also likely; but given that the complaints are sudden and there is no history of fever yet, I'd go with deep vein thrombosis.
Clinical examination followed by tests - blood counts as well as D-dimer tests would help us arrive at the diagnosis.
Hope you agree. Let me know if you need to discuss further.
Regards
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
what other diagnosis would you come up with, with this case study?
Brief Answer:
Symptoms are distinctive...
Detailed Answer:
Hi,
In this case, the symptoms are unilateral and limited to the left calf. Unilateral limb pain are associated with venous clots / congestion, arterial blocks, nerve compression (sciatica), varicose veins and inflammation (tendinitis/dermatitis/venous thrombophlebitis)/ infection. These are the differential diagnosis for unilateral leg pain pain.
Was there history of vein punctures in the affected limb?
Does the patient have history of diabetes, cancers and immunosuppressive status?
Based on the history provided the three close differentials are DVT, cellulitis and superficial venous thrombophlebitis? As you mentioned there is no other significant history I assume there is no history of vein punctures, diabetes, cancers, back pain, injury and there is no history of varicose veins and past history of similar complaints. Therefore in my opinion the symptoms are distinctively in favor of Deep vein thrombosis. Cellulitis being the next differential.
Hope this answered your question. Let me know if you need clarifications.
Regards
Symptoms are distinctive...
Detailed Answer:
Hi,
In this case, the symptoms are unilateral and limited to the left calf. Unilateral limb pain are associated with venous clots / congestion, arterial blocks, nerve compression (sciatica), varicose veins and inflammation (tendinitis/dermatitis/venous thrombophlebitis)/ infection. These are the differential diagnosis for unilateral leg pain pain.
Was there history of vein punctures in the affected limb?
Does the patient have history of diabetes, cancers and immunosuppressive status?
Based on the history provided the three close differentials are DVT, cellulitis and superficial venous thrombophlebitis? As you mentioned there is no other significant history I assume there is no history of vein punctures, diabetes, cancers, back pain, injury and there is no history of varicose veins and past history of similar complaints. Therefore in my opinion the symptoms are distinctively in favor of Deep vein thrombosis. Cellulitis being the next differential.
Hope this answered your question. Let me know if you need clarifications.
Regards
Note: For further inquiries on surgery procedure and its risks or complications book an appointment now
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
Get personalised answers from verified doctor in minutes across 80+ specialties
