Morning Report .


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Morning Report. Danielle Behrens D.O. PGY2 August 18, 2009. Boss Dissension. Respective Leg torment left > right. History of Present Ailment. 47 year old female presents to the ED with a boss grumbling of reciprocal leg torment L>R.
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Morning Report Danielle Behrens D.O. PGY2 August 18, 2009

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Chief Complaint Bilateral Leg torment left > right

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History of Present Illness 47 year old female presents to the ED with a central protestation of two-sided leg torment L>R. States torment started 2 months prior LLE calf agony and extraordinary toe deadness, more terrible with ambulation; enhanced with rest. Pt was seen at OLOL ED 1 month prior had Duplex u/s –negative. Pt took Ibuprofen and torment made strides. Pt then created dynamic agony in b/l feet with deadness still more awful with ambulation and enhanced with rest-saw PCP-no reviews done around then. Torment has been deteriorating over most recent 3 days-now not diminished by rest

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History of Present Illness Pt went to ED everywhere inward city healing facility 5 days earlier was released from ED-advised to catch up with PCP. Additionally offered referral to Neurologist. Pt again displayed to ED everywhere internal city doctor\'s facility 2 days earlier with compounding agony Was given Percocet and released home. Pt states agony is relentless more awful with introduction to frosty;

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PMHx: Asthma Uterine Fibroids GERD Seasonal Allergies PSHx: Tubal Ligation Social Hx: 15 pack year smoking history ( ½ ppd x 30 years) Occasional ETOH Denies IVDA/+ cocaine utilize 30 years prior Works as an educator\'s partner/transport associate

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Family Hx: Non Contributory ROS: b/l LE torment Paresthesias b/l feet Cold prejudice b/l LE

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Physical Exam VS: T: 99.5 HR: 114 RR: 18 BP: 138/78 O 2 Gen: AAO x 3, Uncomfortable HEENT : NCAT, EOMI, PERRLA CV: tachycardic RR no mumbles, rubs runs Lungs: CTA b/l no wheezes, rales, rhonchi Abd: delicate, NT/ND BS + 4, no throbs Back: No CVA delicacy Ext …

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… Feet excessively touchy to touch L>R, L foot pale and cool. Toes on R foot purple shading with top refill 3-4 secs. PT beat recorded on doppler. Photograph from Oncology Nursing Society www.ons.org

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Now what?

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CT with complexity: L regular corridor thrombus without finish deterrent.

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Tx to CUH ICU IV aorta with overflow Large ovoid portable thrombus found withinn the distal stomach aorta, left unconventional which reaches out into the left basic iliac corridor. Single vessel spillover on the left with assumed distal embolization of proximal peroneal and back tibial conduits.

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Thrombectomy done by vascular surgery Remained in ICU-Left foot logically more ischemic/necrotic Underwent Left BKA

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2 D resound: Normal LV size and divider thickness. LVEF: 60-65% Normal RV size and capacity Normal LA; Normal RA; Normal Interatrail septum. Negative Bubble concentrate No masses seen.

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Consult Heme/Onc…

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Results: Factor V Leiden-negative Prothrombin quality transformation negative AT III-67 Homocysteine: 9.6 Protein C: 27.4 Protein S: 58 Fibrinogen: 492 B2 Microglobulin I: Neg IgA, IgM & IgG

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Results: Anti-Cardiolipin Ab: POSITIVE IgA, IgM, IgG NEGATIVE Lupus Anticoagulant: dRVVT: ** 61.4 sec** (28.8-42.0) Hex Phase: ** 59.7 ** (<8.0)

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Antiphospholipid Ab Syndrome Disorder of coagulation related with blood vessel and venous thrombosis Also connected with repetitive fetal misfortune

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Antiphospholipid Ab Syndrome APS Criteria-reconsidered 2006 *Must have 1 clinical criteria and 1 lab criteria for dx* 1. Vascular thrombosis 2. Pregnancy dreariness - at least three SABs <10 wks incubation at least one SAB >10 wks growth at least one untimely births <34 weeks development assoc. with Preeclampsia/eclampsia or placental insuffuciency. 3. Nearness of anticardiolipin, Lupus anticoagulant or Anti-B2 Glycoprotein antibodies

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Antiphospholipid Ab Syndrome Primary APS-APS without Rheumatologic Disease Secondary APS-APS within the sight of Rheumatologic Disease Ex: SLE with Lupus anticoagulant ** Important-Pt can have Lupus anticoagulant without SLE**

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Antiphospholipid Ab Syndrome Cardiolipin - mitochondrial layer phospholipid B2 Glycoprotein I-phospholipid restricting protein Lupus anticoagulant-antibodies that draw out the coagulation time.

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Antiphospholipid Ab Syndrome Anticardiolipin antibodies are more touchy Lupus anticoagulant is more particular

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Catastrophic Antiphospholipid Ab Syndrome Multiple thrombi in at least 3 organ frameworks over days to weeks Mortality rate half Death happens from multiorgan disappointment Kidneys are most influenced taken after by lungs, CNS, heart, skin

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Treatment Aimed at : Prophylaxis Treatment of thrombi Prevention of future thromboemboli Management in pregnancy

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References "The Antiphospholipid Syndrome" Jerrold S. Levine, M.D., D. Product Branch, M.D., and Joyce Rauch, Ph.D. The New England Journal of Medicine Volume 346:752-763 March 7, 2002 Number 10 Photo from Oncology Nursing Society www.ons.org

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