Hot Seat #166: Worsening Leg Pain

Posted on: February 22, 2021, by :

Author: Raj Sood, MD

HPI: 17 year-old boy is presenting to the ED with 4 days of progressively worsening right lower extremity pain. Reports that the pain began in the back, and has since migrated the down the right side and includes the groin and leg (all on the right side). Pain is so bad that he cannot sleep. He was seen at a community hospital where he had a fever to 38.3 C and was subsequently transferred to your academic center.

ROS: No prior illness, URI sx. No chest pain or shortness of breath. No weakness or sensory deficits. No swelling in other joints or extremities.

He denies any recent trauma.

PMHx/Meds: Depression (fluoxetine), seasonal allergies (Cetirizine)

FHx: No history of autoimmune disease, no history of arthritis

SHx: Denies tobacco, THC, alcohol or other drug use. No recent travels

Physical Exam:

VS: T 38.2, HR 114, RR 22, BP 129/73, O2 Sat 98% RA, Wt 85 kg

General: in mild distress due to pain, non-toxic  
ENT MMM, OP clear without erythema or exudates, TM’s clear b/l
Lymph: No LAD.
CV: tachycardic, regular rhythm,  no murmurs or rubs. Cap refill < 3 secs.
Pulm: Good air entry bilaterally, no wheezing or crackles. No retractions
Abd: +BS, soft, NTND, no HSM

MSK: significant RLE non-pitting edema with overlying bluish discoloration traversing hip to foot, very tender to palpation over entire extremity, 2+ DP and PT pulses, moves extremity without assistance but reports pain with movement

Neuro: awake and alert, no neurological deficits, 5/5 strength in all 4 extremities, SILT throughout RLE
Skin: warm and dry, no rashes.

EKG: shows sinus tachycardia HR 119, no ST segment changes, no T-wave abnormalities, normal intervals.

Duplex lower extremity ultrasound shows: extensive occlusive deep venous thrombosis of the R lower extremity, involving the common femoral, superficial femoral, popliteal and calf veins. The ultrasound tech is unable to assess the iliac system for clot.

CRP is 9.9 mg/dL.

The patient continues to be febrile (38.3) and mildly tachycardic (116).

CTA of the abdomen and pelvis revealed extensive acute DVT involving the R common iliac vein, external and internal iliac veins, common femoral vein, and proximal femoral vein with narrowing of the R common iliac vein as it crosses under the common iliac artery.

The patient continues to be in moderate to severe pain intermittently requiring morphine.

Brian Lee
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