Potential DVT/PE?

[cdblackburn14]

I have a patient that is really getting my patho juices flowing.

67 yr old male with HTN and liver disease that has been resolved. Gets MRI twice a yr and keeps up with blood tests.

Recently had pneumonia about 3-4 months ago that was treated at home and has been resolved.

Recently the patient has been having shortness of breath just by walking, as well as a dry cough.

Lung doctor tried a breathing treatment which didn't help. I am unsure if they looked at the lungs directly but he was sent to cardiologist bc no abnormalities were suggested. All lab work came back normal. On paper the patient is healthy as a horse. Did a exercise stress test and showed a reversible defect on lateral wall of the heart. Heart cath was done and blood flow showed to be normal and stress test was then decided to be a false positive.

Patient is to follow up with doc to figure out next steps.

I am starting to try and think of other reasons. I asked the patient if he has had any pain or cramping in his calves, he reported no. When measured, the left is half an inch larger. I am beginning to wonder if this could be a DVT developing into a PE.

Thoughts?

[Cat365]

You can't always trust calf measurements. It could be larger because he uses that side more. Someone who routinely does a repetitive motion or that has a leg length discrepancy will also be larger on the longer/more used leg. Pain/redness would be typically found with a DVT.

Any medications that could cause coughing?

[nrsang97, BSN, RN]

Any medications that the patient is on such as ACE or ARB's for BP?

[Libby1987]

I'd want a CT of my chest, not all lung disease shows up on a CXR. And pulmonary function, surely they already did that?

[KatieMI, BSN, MSN, RN]

ACEIs?

GERD?

Obese?

Chronic synusitis? (yes, it can cause sensation of SOB and cough... with everything else negative. Especially with polyps).

Is he a smoker? (and, if so, of what?) What he is doing for life? What he did before?

What sort of liver disease it was that "resolved" but still requires MRI twice a year? How it was treated?

All meds he was/is, over last 5 years?

How long he is living with HTN, how well it is controlled?

What was his LVEF (should be done during cath)? Any U/S recently?

Anything steering toward asthma? COPD?

Varicose veins?

Again, what he is doing for life (truck driver? dedicated couch potato?)

Recent leg traumas or high risk for them?

DTaP status? Any contact with sick little children, Tb?

Fever, malaise, fatigue, low energy, weakness, sweats (systemic pathology like sarcoidosis)

Now:

Homan's sign: less than 33% of patients with DVT.

Difference in calf circumfetence of 1/2 inch is normal (we're all a bit non-symmetric)

As for information given, unless the guy has some obvious risk factors (sits for hours, flies very often, had DVT before, family h/o cloths/unexplained pregnancy loss, known clotting system anomalies found before like Leyden) DVT (which is NOT the same thing as PE) would be my very much back burner pot. I would start from a GOOD physical and even better history, then CBC/CMP/chest xray/synus xray if nothing else found on physical. PFTs would be good idea, as well as ECG (right overload signs). No necessity to run expensive/high xray load tests like CT scan or angio unless we are so much unsure what we're looking for and where.

And, someone with long-standing HTN and something with liver when an MRI scan is determined to be needed every 6 months cannot be healthy as a horse. MRI Q6 is appropriate for things like liver mass surveillance, so unless doc is practicing CMA medicine quite heavily, then there got to be some serious readon for doing that.

[cdblackburn14]

Unsure of all medications. A few for BP but that's it.

[cdblackburn14]

Pt isn't a smoker.

He has been retired for almost 10 yrs but lives a very active life.

Liver disease is cirrhosis. Dx 5yrs ago. Had to have about 2L of fluid removed from abdomen. Since then doctors have reported liver to be working fine. Still a mystery as to how.

HTN very well controlled. Was in the 110 teens over 70's before his heart cath.