Swollen
Cardiovascular System
0
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M2_F1.jpg"}},{"insert":"\n\n\u0022It never rains in Cali...\u0022 you hum to yourself. After a well-deserved two-week vacation in Bali, you feel recharged and ready to face the day-to-day stress of your job.\n\nYour pager buzzes\u2014a new patient has arrived. Hurrying over, you are introduced to 72-year-old Susan. After formally introducing yourself, you ask her why she came in today. \u201cOh, doctor\u2014my leg has been swollen for the last few days,\u201d she responds.\n"}]}
1
{"ops":[{"insert":"Susan developed pain and swelling of her right calf around 3 days ago. She went to see her primary care provider, who diagnosed cellulitis and started her on oral cefixime. However, the swelling and pain persisted; and in fact, she feels that they have become worse since.\n\nSusan was diagnosed with type 2 diabetes mellitus around 10 years ago. This is well controlled on oral metformin 850 mg bd. She was diagnosed with grade 1 diabetic retinopathy around six months ago but has no other microvascular or macrovascular complications. Perusing her most recent reports (around one month ago), you note that her renal functions were normal; her urine was negative for microalbuminuria; and that her eGFR is age appropriate.\n\nYou also note that Susan underwent arthroplasty of her left knee just 2 weeks ago, due to severe osteoarthritis. The surgery was successful and the recovery uneventful. \u201cSuch a relief, doctor \u2013 I should have gone for the operation long before,\u201d she says. Susan also has osteoarthritis of the right knee and intends to request arthroplasty for that knee as well, down the line.\n\nSusan lives alone. Her husband of almost 50 years died a year ago. She has three grown-up sons, all of who live in different cities.\n"}]}
2
{"ops":[{"insert":"Proceeding to the examination, you note that Susan\u0027s temperature is 98.6\u02daF (37.0\u02daC). Her pulse rate is 90 bpm, blood pressure is 120\/80 mmHg, and respiratory rate is 12\/min. Pulse oximetry shows an oxygen saturation of 99%. The general examination is unremarkable. \n\nExamination of the right lower limb reveals moderate swelling of right calf and foot, without erythema or skin changes. The swollen area is not tender. Pitting edema is present. The circumference of the right calf (as measured 10 cm below the tibial tuberosity) is ~4 cm greater than that of the left calf. There is no tenderness along the deep venous territories of the right lower limb. All peripheral pulses are normal. There is no inguinal lymphadenopathy. Both active and passive movements of the right knee joint and hip joint are painless. There is palpable crepitus over the right knee, consistent with the existing osteoarthritis.\n\nExamination of the left lower limb is unremarkable. Cardiorespiratory and abdominal examination are also unremarkable.\n"}]}
3
{"ops":[{"insert":"Examination over, you ponder what the probable diagnosis is.\n\nWhich of the following are you thinking of?\n"}]}
1. Ruptured Baker's cyst
2. Cellulitis
3. Deep vein thrombosis
5
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6
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7
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4
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