Discussion:
Based on the case presentation above, formulate the patient’s diagnosis and provide 2 differential diagnoses. Based on your diagnosis, discuss the pharmacological treatment plan. Briefly discuss the pathophysiology, risk factors, and current pharmacological therapies, as evidenced by the literature.
Make sure to provide citations and references (in APA, 7th ed. format) for your work.
A 70-year-old woman was recently discharged following exploratory laparotomy for perforated duodenal ulcer with peritonitis. The patient presented on discharge day 4 with complaints of right-sided pleuritic chest pain that started the day after discharge. Pain was described as dull in nature, 5/10 in severity, radiating to the right upper quadrant, aggravated by deep respiration and associated with cough productive of whitish sputum. The patient admitted to having chills but denies fever, shortness of breath or palpitations. The patient denied diarrhea or constipation. The patient denied having bloody or black stools. Her medical history included hypothyroidism, hypertension, GERD and peptic ulcer disease.
Physical examination of the patient revealed an obese woman in mild distress. Her blood pressure was 122/77 mmHg with a pulse of 86 beats per minute. She was breathing 16 times/minute with an oxygen saturation of 100%. She was afebrile. On head and neck examination, her pupils were equal, round, reactive to light and accommodation. Her sclera was anicteric, revealing mild pallor. On cardiovascular exam, heart sounds were audible with regular rate and rhythm, normal S1 and S2, no murmurs. Her lung fields had decreased air entry bilaterally, right side greater than left. Her abdomen had surgical stables present along the midline with tenderness around the surgical site. Her extremities were symmetric without tenderness, cyanosis or pedal edema. Her pulses were present and palpable bilaterally.
Her blood chemistry panel revealed a serum sodium of 132 mmol/L, potassium of 3.6 mmol/L, chloride of 102 mmol/L, bicarbonate of 22 mmol/L, BUN of 15 mg/dL, creatinine of 1.0 mg/dL and glucose of 92 mg/dL. Her Leukocyte count was 16.0 x103 per µL, with 83% neutrophils. Her hemoglobin was 10.1 g/dL, hematocrit 29.5% and platelet count was 170 x103 per µL. Arterial blood gas sampling showed a pH of 7.48, PaCO2 of 33 mmHg, PaO2 of 77 mmHg, and 97% and FiO2 of 21%. Chest x-ray revealed pneumonia in the right lung. The patient was diagnosed with hospital-acquired pneumonia and treated with intravenous fluids, IV Cefepime and Ciprofloxacin, Levothryoxine, Nexium and Lotrel.
On hospital day 2, the patient reported improvement of symptoms. Vital signs were within normal limits. Leukocyte count was 8.0 x103 per µL. Hemoglobin was 8.6 g/dL, hematocrit was 26% and platelet count was 118 x103 per µL. CT scan revealed an improving pleural effusion. CBC was monitored with a discharge plan if leukocytes were trending downward. In the evening, the patient complained of left knee pain. Physical exam revealed erythema around the lateral aspect of the left knee. Patient denied any trauma but states that the Flow-tron was a little tight. The Flow-tron was loosened and Tylenol was given for pain management. An hour later, the patient was re-evaluated. The entire left leg was noted to be swollen and now tender to touch. An assessment of deep vein thrombosis (DVT) was made and the patient was started on heparin infusion.
On hospital day 5, lower extremity duplex scan showed acute thrombosis of left common femoral, superficial femoral, popliteal, tibial and saphenous veins, with absence of flow and compressibility. The right popliteal vein also showed chronic re-canalized thrombosis. Leukocyte count was 9.9 x103 per µL, hemoglobin was 8.5 g/dL. Hematocrit 24.7%, platelet count was 89.2 x103 per µL. Platelets on admission were 170 x103 per µL. Serotonin release assay was 100%.