Case – 6

Case – 6

Diagnosis 

DVT left leg with suspected PE with secondary varicose veins

History

The patient had painful swelling left leg for the past 8 months. This was proven on colour Doppler study to be Ilio-femoral DVT. He was on treatment for DVT but unfortunately defaulted on a number of occasions not taking the medical advise offered to him.

Recently he had shortness of breath which was persistant.

PMH

The patient has been on reasonably good health with no cardiac or respiratory problems in the past. There is no history of diabetes

The ptient was in good general health and not in obvious pain. The leg showed no swelling. There were no grossly dilated veins on the left leg. Normal pulsations were present at the ankle. There was an area of discolouration above the left medial malleolus. There were no ulcers.

Immediate investigations

Bloods – 

Hb – 13.7 gm% TLC – 11700 μ/l Platelets – 288000 μ/l

RBS – 93 mg% Urea – 17 mg% Createnine – 0.7 mg%

Na – 137 meq/l K – 4.1 meq/l PT – 19.3/12 sec

PTT – 28/28 sec

CXR – WNL

ECG – WNL, no right heart strain

Colour Doppler study – 

It showed ilio-femoral DVT on the left leg with partial rechanalization. There was incompetence of the long saphenous vein at the SFJ and there were two large perforators in the leg which were responsible for the discolouration and impending ulceration.

Hospital Course

The patient was treated conservatively with foot elevation, stockings and anticoagulation. The main reason to admit him was to exclude the possibility of PE secondary to DVT and to monitor any episodes of breathlessness while in hospital. Secondary varicose veins are never treated surgically.

Condition on discharge

Mostly unchanged. The leg was soft with minimal swelling. The dermatitis was present on the medial aspect above the malleolus.

Advise on discharge

  1. Salt restricted diet
  2. leg elevation at night without stockings
  3. Normal activity during the day but with stockings
  4. Leg elevation for 10 mins every 2 hours during the day with stockings
  5. Tab Warf 5 mg od
  6. Blood for PT only weekly and inform
  7. To attend OPD regularly twice a month
  8. Once the veins are cleared of organized thrombus then the patient may need ligation of the perforators on the left leg to control the dermatitis and impending ulcer. This would be only done once the vein is cleared of the clot which would probably take months. 

(Dr. Jaisom Chopra)

Consultant Vascular Surgeon