37 - Case Study I Flashcards
Lecture objectives
- Biomarkers for liver and bone disease
- Diagnostic tests for bone disease
- Relationship between liver disease and DVT
- Clinical signs and diagnosis of DVT
Case study
- 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
Past medical history
- 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
Review of systems
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
Physical exam
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
Radiographic findings
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
Plan
- 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
Results
- Alkaline phosphatase = 184 (double the normal value)
- LDH = normal
- AST = 42 (normal is 6-23, double)
CBC with diff is normal
AST elevation
Could be pathology in the…
- Heart
- Liver
- Skeletal muscle
Alkaline phaosphatase elevation
Could be pathology in the…
- Liver
- Bone
The common denominator here is the liver
What other test should we order?
ALT
Another liver enzyme that we should have ordered
Describe the bone scan (went back in charts and reviewed)
“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
What is the next step?
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
What was the outcome?
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
6 weeks post op
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
What are the other possibilities other than DVT?
- Compartment syndrome
- Muscle atrophy followed by activity (inflammation of muscle or myocitis) - precursor of compartment syndrome
- Infection or cellulitis
What do you do next?
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
What did he do next?
Angiography, venogram
RBCs are labeled with tech 99, so the higher the volume of RBCs, the higher the intensity of the image
What were the results of the angiography or venogram?
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
What was the diagnosis?
- 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)
Why is this a concern?
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
What are the treatment option
- Thrombolytics (
Describe the possible etiolgies of the DVT
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
What is the treatment plan?
- Admitted to hospital
- Anticoagulation via heparin to therapeutic level
At this point, patient complained of left lower quadrant flank pain
What should you do now?
CT
She has a lesion that now occupies 1/3 of the liver
What was this lesion?
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.
What else was seen?
Kidney problem?
What was the diagnosis?
Patient had a hypersensitivity to heparin and developed a retroperitoneal bleed
What was then done?
Heparin was therefore discontinued and was placed on coumadin
Should the surgery have been done?
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
