Yesterday one of the young doctors presented an interesting case to me. It had been presented to several others with no diagnosis.
A 26 year old male had acute onset of severe pain, redness and swelling in both feet several hours before presenting to a local ER. He had a MVA years ago and 12 subsequent surgeries to this leg.
He had no chronic diseases. He is a construction worker and drove a bull dozer all day. His pain was severe requiring multiple doses of narcotics without relief. Both feet were swollen and red with some extension into his lower legs.
Lab --cbc, lytes, cmp, xrays, sed rate all normal with the exception of his LDH which was double the normal value.
Questioned about resources used: "called everyone I could think of , Googled it, searched all my texts and no answer".
What is your differential dx starting with the most likely of course.
cogitating.....
ReplyDeleteReflex Sympathetic Dystrophy can be bilateral in up to 25% of cases so I would say that is a possibility though I don't think an elevated LDH is typical with this condition. Or maybe he had Bilateral lower extremity DVTs but I think the LDH is still a problem. also in the differential would be cellulitis, or a contact dermatitis from his boots or a irritatant dermatitis from something he was working around that got in his boots. Now that I think about it, you seemed to put a little emphasis on not just driving a bulldozer, but driving it ALL DAY. Heck yes BLE DVT is my final answer!!
ReplyDeleteyou picked up on most of the clues:
ReplyDelete1. LDH
2. bilateral
3. driving all day in boots
4. the most important, Google, mistake almost made; assuming the young doctor had done an adequate Google search. Try it yourself and see what you find.
Well of course I googled various combinations of the above clues but none of the results led me to any of my diagnoses in the differential or my final answer. Are you saying that my diagnosis was incorrect?
ReplyDelete