Mrs. Patel I: Leg Swelling

Immune System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M1_F1.jpg"}},{"insert":"\n\nYour stomach grumbles. Lunchtime is close and the hospital cafeteria beckons.\n\nThe door opens once more, and an elderly lady is wheeled in. You are introduced to 56-year-old Mrs. Patel and her son Rahul.\n"}]}


{"ops":[{"insert":"Mrs. Patel complains of pain and swelling of her left leg since last night. She has also felt feverish since waking up in the morning. No other symptoms are present.\n\nMrs. Patel was diagnosed with type 2 diabetes mellitus six years ago. She has not been followed up regularly; and she has been poorly compliant with both drug therapy and lifestyle changes. Her most recent follow-up was 12 months ago. At that visit, her HbA1C was 8.8%. She was also found to have grade 2 diabetic retinopathy, while her urine albumin:creatinine ratio was 12 mg\/mmol (i.e., microalbuminuria). However, her eGFR was 92 ml\/min\/1.73m2 (normal: 90-120). She is currently on oral metformin 850 mg bd and oral gliclazide 80 mg od.\n\nMrs. Patel\u0027s surgical history is only significant for a lower segment Caesarean section at 40 years of age, without complications. Her family history is unremarkable. Mrs. Patel lives with Rahul, who is a manager at a nearby department store. She has no other children. Her husband died of a \u201cheart attack\u201d just over a decade ago.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M1_F2.jpg"}},{"insert":"\n\nOn examination, you note that Mrs. Patel\u0027s pulse is 96 bpm and regular; her blood pressure is 120\/80 mmHg; her respiratory rate is 14\/min; and her temperature is 100.7 \u00b0F (38.1 \u00b0C). \n\nExamination of the left lower limb shows the left calf and foot to be erythematous, swollen, and tender. The circumference of the left calf (as measured 10 cm below the tibial tuberosity) is 2 cm greater than that of the right calf. There is no tenderness along the deep vein territories. All peripheral pulses are normal. A 1 cm x 1 cm superficial wound is present in the first web space. There is no inguinal lymphadenopathy.\n\nExamination of the right lower limb is unremarkable. Cardiorespiratory and abdominal examination are also unremarkable. Mrs. Patel\u0027s capillary glucose is 245 mg\/dL (13.6 mmol\/L).\n"}]}


{"ops":[{"insert":"Which of the following diagnoses do you consider to be most likely?\n"}]}
1. Deep vein thrombosis
2. Cellulitis
3. Ruptured Baker's cyst