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GI and Renal Exam 3 > 37 - Case Study I > Flashcards

37 - Case Study I Flashcards

1
Q

Lecture objectives

A
  • Biomarkers for liver and bone disease
  • Diagnostic tests for bone disease
  • Relationship between liver disease and DVT
  • Clinical signs and diagnosis of DVT
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2
Q

Case study

A
  • 59 year old female
  • Complain of painful bunion on L foot
  • Presents with “many years” of pain
  • Would like to have the condition corrected surgically
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3
Q

Past medical history

A
  • Store clerk and spends many hours on her feet
  • Allergies to sulfa drugs (rash, difficulty swallowing, many years ago)
  • Medications - labetalol, estrogen and aspirin daily
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4
Q

Review of systems

A

Cardiovascular
- HTN under medical management

Endocrine
- Appropriate bone health for gender and age, self-reported

GI

  • Long standing idiopathic elevated alkaline phosphatase and a “liver enzyme”
  • Identified by primary care, but did not link it to anything

MS

  • Had total body bone scan to rule out bone pathology (tech 99 scan)
  • Scan is non-specific but is very sensitive, test was normal

Hematologic
- No bleeding issues

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5
Q

Physical exam

A

Neurovascular
- Neurovascular status intact

Dermatological
- Skin temperature, texture and turgor normal

Musculoskeletal

  • Abductus deformity of the left hallux without tracking of the 1st MTPJ and decreased dorsiflexion
  • Muscle strength 5+ for all muscle compartments of the lower extremity
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6
Q

Radiographic findings

A 
IMA = 16
HHA = 40
PASA = 8 degrees
DASA = 6 degrees

1st metatarsal protrusion +2mm (first metatarsal was 2 mm longer than the second metatarsal)

Quality of bone appeared good

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7
Q

Plan

A
  • Past medical history of liver issues deserves a workup
  • It has been all word of mouth so far, so order liver enzymes

Order pre-op tests

  • EKG, chest x-ray
  • CBC with diff
  • Liver enzymes

Picking the procedure

  • The more proximal you go, there will be a period of non-weight bearing
  • Need to consider
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8
Q

Results

A
  • Alkaline phosphatase = 184 (double the normal value)
  • LDH = normal
  • AST = 42 (normal is 6-23, double)

CBC with diff is normal

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9
Q

AST elevation

A

Could be pathology in the…

  • Heart
  • Liver
  • Skeletal muscle
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10
Q

Alkaline phaosphatase elevation

A

Could be pathology in the…

  • Liver
  • Bone

The common denominator here is the liver

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11
Q

What other test should we order?

A

ALT

Another liver enzyme that we should have ordered

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12
Q

Describe the bone scan (went back in charts and reviewed)

A

“Hot spots”

  • Some places where the tech 99 was taken up
  • Not that uncommon in an older woman who works on feet
  • Degenerative bone disease in major joints
  • What you really look for in these scans is UNUSUAL areas of uptake (skull), but nothing abnormal is present
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13
Q

What is the next step?

A

Referred to the primary care

  • Said he has looked into this condition
  • Never had history of complaints of pain
  • Very convinced that it was idiopathic and not a concern
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14
Q

What was the outcome?

A

NOT GOOD

  • The bone was mush
  • Had to change plans
  • Had an unstable fixation
  • Non-weight bearing, but encouraged to move around as much as possible
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15
Q

6 weeks post op

A

Cast came off, then come back 1 week later with pathology

Pain, swelling, warmth of the lower extremity, bluish tint to the leg, diameter larger than other

DVT is only one of the things you would consider

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16
Q

What are the other possibilities other than DVT?

A
  • Compartment syndrome
  • Muscle atrophy followed by activity (inflammation of muscle or myocitis) - precursor of compartment syndrome
  • Infection or cellulitis
17
Q

What do you do next?

A

Get lab values

Evaluate DVT

  • Duplex ultrasound is first line (can get a false negative in the lower extremity)
  • D dimer
  • Angiography venogram is gold standard
18
Q

What did he do next?

A

Angiography, venogram

RBCs are labeled with tech 99, so the higher the volume of RBCs, the higher the intensity of the image

19
Q

What were the results of the angiography or venogram?

A

There is a clear difference between the legs

  • Highlighting or higher intensity (could be white or dark, depending on the scan) right below the knee
  • Problem on the left leg
  • RBCs are concentrated here
  • The dark (black) areas are the clot - little to no blood flow
  • The bright area is how the leg should look
20
Q

What was the diagnosis?

A
  • DVT
  • On the operated leg below the knee
  • If you’re looking at a below the knee concern, it is better to go with a venogram or angiography (US may not have picked this up)
21
Q

Why is this a concern?

A

Pulmonary embolism

  • Clot breaks off, goes to heart, goes to lung
  • If the clot is below the knee, the chance of embolism is lower than if it was above the knee
22
Q

What are the treatment option

A
  • Thrombolytics (
23
Q

Describe the possible etiolgies of the DVT

A

Hypercoagulable states

  • Factor V
  • Protein S deficiency, protein C deficiency
  • Elevated factor VIII
  • Antithrombin III deficiency
Age over 60
Immobilization 
Fracture of the pelvis, femur or tibia
Malignancies
Obesity
Pregnancy
Estrogen use
24
Q

What is the treatment plan?

A
  • Admitted to hospital
  • Anticoagulation via heparin to therapeutic level

At this point, patient complained of left lower quadrant flank pain

25
Q

What should you do now?

A

CT

She has a lesion that now occupies 1/3 of the liver

26
Q

What was this lesion?

A

It was first thought that it was a bleed, but it didn’t quite match up with symptoms - biopsy was never done since it was not known if it was a bleed or not. The lesion never changed in appearance after surveillance, so it was therefore considered to be a benign lesion and too high of a risk to do anything about it. Possible that it had been there the whole time.

27
Q

What else was seen?

A

Kidney problem?

28
Q

What was the diagnosis?

A

Patient had a hypersensitivity to heparin and developed a retroperitoneal bleed

29
Q

What was then done?

A

Heparin was therefore discontinued and was placed on coumadin

30
Q

Should the surgery have been done?

A

No

  • Too much risk
  • Should not have listened to the primary care provider who said there was no contraindication
  • Even if she had been anti-coagulated, it would not have prevented this because this happened 6 weeks following the surgery and it would have been discontinued by then

GI and Renal Exam 3 (15 decks)

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