|26.3 kg/m 2
Ms. Smith is a 52-year-old woman 6 weeks status post knee replacement surgery presenting to the ED following two episodes of sharp chest pain lasting 5-10 minutes and accompanied by dyspnea.
Ms. Smith, a 52 year old woman, goes to the Emergency Department because she felt a sharp pain in her chest while she was at work. She has been working as a manager at a hair salon in the mall for the past 6 years. She was admitted about 6 weeks ago for a left knee replacement. She had to go back to work after the knee surgery sooner than expected. Today she has been having trouble moving around because she is easily fatigued. She was able to keep up despite the fatigue until about an hour into the job, when she suddenly started feeling sharp, 5/10 pain on the left side of her chest. She tried sitting and resting without much relief. The pain worsens when she takes a deep breath. Her discomfort was accompanied by shortness of breath, but she has had no sweating, nausea, or vomiting.
The first episode of chest pain occurred when she was cooking dinner yesterday. The pain lasted for approximately 5-10 minutes and disappeared. She sat down for a while and felt better so did not think much more about it. Since that episode of chest pain, this is the first time she has experienced similar pain. At no time has she attempted any specific measures to relieve her pain, other than rest. She becomes short of breath during these episodes, but describes no otherShortness of breath triggered by physical activityexertional dyspnea , Shortness of breath that occurs while lying flat, and is relieved upon sitting up or standingorthopnea , or Sudden, severe shortness of breath that occurs during sleep and awakens the patient, and is usually relieved by sitting upnocturnal dyspnea . Otherwise, she describes no other associated symptoms during these episodes of pain, including dizziness, nausea, Excessive sweating (not due to physical exertion or temperature)diaphoresis , or palpitations.
She thought the recovery from the knee surgery was going well. The swelling in her knee and leg had gotten much better, the pain was almost gone, and she has been working hard at physical therapy to increase her range of motion. However, since she’s had to start working again, she hasn’t been keeping up with PT as well. She also noticed the swelling getting worse.
|No fever, chills, or sweats. No nausea, vomiting or sweating during incident. Acute-onset leg swelling and pain; some
Twisted, enlarged veins due to weak or damaged valves; most commonly appear on the legs and feet. Also known as varicose veins.spider veinson left leg.
|No changes in vision.
|Head and Neck
Shortness of breath triggered by physical activityexertional dyspnea,
Shortness of breath that occurs while lying flat, and is relieved upon sitting up or standingorthopnea,
Sudden, severe shortness of breath that occurs during sleep and awakens the patient, and is usually relieved by sitting upparoxysmal nocturnal dyspnea. No sputum production. No
Coughing up of blood from the lower respiratory tract (bronchi, larynx, trachea, or lungs)hemoptysis.
|No dizziness or palpitations.
|No changes in stool pattern, consistency, or color.
Pain, discomfort, or burning when urinatingdysuria,
Excessive urination at nightnocturia,
Excessive or abnormally large passage of urine (less than 3 L/day over 24 hours)polyuria,
Presence of blood or red blood cells in the urinehematuria, or vaginal bleeding.
|No weakness, numbness, or incoordination. No complaints of
|Feeling weak recently. No left arm pain or radiation.
Anticoagulant (low molecular weight heparin) used for prophylaxis and treatment of DVT. Also known as Lovenox (brand name).Enoxaparin
|40 mg twice daily for 2 weeks after surgery (patient no longer taking)
|800 mg every 8 hours as needed for post-op pain (patient no longer taking as of 2 weeks ago)
|As needed for heartburn
|Left knee replacement six weeks ago. She took her prescribed post-op DVT prophylaxis.
|Once for knee replacement surgery. Preoperative labs including BMP and CBC were normal.
|No known drug allergies.
|Normal colonoscopy at age 50, normal pap screen at age 52, and normal mammography at age 52.
|Up to date per patient.
|2 months ago for pre-operative evaluation.
|Passed away at 62 due to coronary artery disease.
|Currently 75 years old and healthy.
|87 years old and had a hip surgery three years ago.
|49-year-old brother who is in good health.
|Two adult children. Both healthy. Both deliveries were vaginal and normal. No spontaneous abortions.
|Other Blood Relatives
|None. No family history of sudden death, clotting disorders, or spontaneous abortions.
|Manager at hair salon in the mall for the past six years. Currently covering two salons because the other manager quit, so she has been working extra. This has caused some stress because of the extra hours, rare days off, and extra managerial duties. She has also had to train many new employees since so many seem to be leaving.
|High school grad.
|She has an occasional drink, usually when socializing on the weekends.
Prior smoker, 10
Unit for measuring amount a person has smoked over a long period of time. Calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the patient has smoked.pack years. She quit when she had her first child.
|Denies any illicit drug use.
|1 cup of coffee per day.
|Unchanged. 3 meals a day.
|Gardening about once a week.
|Gardening, reading, and spending time with close family and friends.
|Stress from her job, but it is not overwhelming. No other major life changes
|Nothing out of the country.
|Monogamous with her husband of 30 years.
|Well-nourished female appearing stated age.
|Normal. Moist mucus membranes, sclera clear, good dentition.
|Normal. Carotid pulses symmetric, no bruits auscultated. No jugular venous distention. No
Palpable enlargement of one or more lymph nodeslymphadenopathy.
|Clear to auscultation bilaterally. Mild dyspnea.
|Normal S1 and S2. Mild tachycardia. No murmurs, rubs, or gallops. Point of maximal impulse not displaced.
|Soft, non-tender, non-distended. No
Abnormal enlargement of one or more organsorganomegaly.
Left leg with 2+
Swelling in the skin that holds a dimple after being pressed for several seconds; occurs due to excess fluid buildup in the body, and most often affects the legs, ankles, or feetpitting edema. Left leg diameter 3 cm larger than right leg. Lower left leg
Abnormal redness of the skin or mucous membraneserythematousand warm. TKR incision site is not tender or
Abnormal redness of the skin or mucous membraneserythematous. Varicose veins present on left. Right leg with 1+
Swelling in the skin that holds a dimple after being pressed for several seconds; occurs due to excess fluid buildup in the body, and most often affects the legs, ankles, or feetpitting edemabut no erythema or tenderness.
|Alert and oriented x4, cranial nerves 2-12 grossly intact, normal finger to nose, normal tandem gait, normal strength throughout, normal speech. Sensory intact to light touch in bilateral lower extremities.
- Acute coronary syndrome
- Cardiac arrhythmia
- Acute pericarditis
- Heart failure
- Pleural effusion
- Asthma or bronchospasm
|8.6 to 10.3 mg/dL
|Complete Blood Count (CBC)
|Comprehensive Metabolic Panel (CMP)
|Alkaline Phosphatase: 88 U/L
AST: 22 U/L
ALT: 38 U/L
Total bilirubin: 0.4 mg/dL
Albumin: 3.8 g/dL
Total protein: 7.7 g/dl/L
Test used to determine the patient’s blood group (ABO) and Rh typeBlood type and screen
|O+ (antibody negative)
Prothrombin time test (PT) measures the speed of blood clotting by means of the extrinsic and common pathways of the coagulation cascade; international normalized ratio (INR) is a standardized conversion of the PT by comparing it to a reference valuePT/INR
|14 sec/1.0 (normal)
Partial thromboplastin time measures the speed of blood clotting by means of the intrinsic and common pathways of the coagulation cascadePTT
|25 sec (normal)
Test that detects poor anticoagulant response to activated protein C (APC), which may increase the risk of thrombosisAPC resistance screen
Genetic test used to evaluate for a variant of human factor V, one of the most common hereditary hypercoagulability disordersFactor V Leiden
Test used to measure the activity of the factor V protein, which serves an important role in the regulation of blood coagulationFactor V Activity
Tests for the presence of a group of prothrombotic immunoglobulins directed against phospholipid-binding proteinsAntiphospholipid antibody panel
Russell viper venom time tests for the presence of lupus anticoagulant, a prothrombotic antibody that binds to phospholipids and cell membrane proteinsRVVT
|34 sec (normal)
Genetic test used to evaluate for a mutation that causes higher levels of the clotting factor prothrombin (factor II), which may increase the risk of thrombosisPT G20210A mutation
Test used to measure the activity of protein C, a natural anticoagulant that is activated to APCProtein C activity
Test used to measure the quantity of protein S, a natural anticoagulant that acts as a cofactor for APCProtein S level
|45 IU/dL (normal)
Test used to measure the activity of antithrombin III, a natural anticoagulant that inactivates several clotting factors in the coagulation cascadeATIII activity
Genetic test used to evaluate for a mutation in methylenetetrahydrofolate reductase, which may result in the development of homocysteinuria, a disorder in which the body is unable to metabolize methionine. Symptoms include lens dislocation, myopia, osteoporosis, and abnormal blood clotting.MTHFR mutation
Test used to measure the activity of homocysteine; elevated levels may increase the risk of thrombosisHomocysteine level
|18 mm/L (normal)
Test used to measure levels of d-dimer, a degradation product of fibrin; elevated levels serve as a marker of activation of coagulation and fibrinolysisD-dimer
|6.45 mg/L (high)
Test used to measure levels of fibrinogen, a glycoprotein that is converted to fibrin to form a blood clotFibrinogen
|CT pulmonary angiogram
|Pulmonary embolus in right main pulmonary artery
Ventilation-perfusion scan is a nuclear medicine test that uses radioactive material to examine airflow and blood flow in the lungsV/Q scan
|High probability V/Q scan by PIOPED criteria
|Lower extremity ultrasound
|Non-occlusive thrombus in distal femoral vein
|Knee X-ray 3 views
|Left knee prosthesis in appropriate position, no fracture, normal soft tissue