The patient is a 65-year-old female who presented with 5 days of left leg pain and swelling. Her medical history includes multiple splenic and renal infarctions diagnosed 2 months ago. On examination, she had edema, redness and tenderness of her left lower limb. Laboratory tests showed mild anemia and thrombocytopenia. Imaging found left popliteal and femoral vein thrombosis.

1. CASE PRESENTATION
DEPARTMENT 31

2. Personal History
 Female patient M.A. 65 years old, House wife,
married with 14 offspring youngest is 35
years old, living in Elsaff ,with no special
habits of medical importance.

3. Complaint
Pain and swelling of left leg

4. Present History
Condition started 5 days before admission by
pain and swelling of left leg of gradual onset
and progressive course, the pain was related
to calf, not radiating, bursting, increasing by
prolonged standing or walking and
decreasing by elevation of the affected leg.

5.  The edema was persistent, increasing by
standing and decreasing by elevation of the
leg.

6.  The condition is not associated with fever,
and not preceeded by trauma, surgical
operations or intake of any drugs.

7.  The condition is not associated with chest
pain, hemoptysis or dyspnea.

8. The patient suffered from left hypochondrial
stitching pain two Months ago and sought
medical care, U/S and CT abdomen were and
the condition was diagnosed as multiple
splenic and renal infarctions.

9. No history of:
Arthralgias or arthritis
Photosenstivity
Oral ulcers
Excessive hairfall

10.  No history of:
 Rapid weight loss
 Generalized body swellings
 Severe headache, projectile vomiting or
blurring of vision.

11.  Chest pain or hemoptysis.
 Right hypochondrial pain or jaundice.
 Persistent bony pains.
 No history of previous strokes, TIAs, myocardial
infarctions, intestinal infarctions or limb ischemia.

12.  No history suggestive of other systemic
diseases.
 The patient is not known to be
hypertensive.

13. Past History
history of previous similar condition.
History of cataract operation done 20 years
ago.

14. Family History
No similar conditions in the family.
Positive consanguinity.( The parents are
cousins.)

15. Obstetric
No history of previous abortions

16. EXAMINATION

17.  The patient is fully concious, of average
mood, and well oriented to time, place and
person.

18. Examination
Vital Signs:
B.p.:120/80
Pulse:80, Regular, of average pulse volume, equal
bilaterally, with no special character. Peripheral
pulsations are intact. Arterial wall is not felt.
Temp: 37.5
R.R.: 20
RBS:269

19. No jaundice
No Pallor
No cyanosis
Carotid pulsations are of average volume and
equal bilaterally
No congested neck veins
No thyroid swelling
No cervical lymphadenopathy

20. Limb examination
Upper limbs:
No clubbing or cyanosis
No flapping tremors or palmar erythema
Lower limbs:
Left lower limb edema, redness and tenderness
Tense calf muscles of the left lower limb
Palpable dorsalis pedis and posterior tibial

21. Cardiac examination
Inspection:
Apex lies in the 5th space in the MCL
No visible pulsations
Palpation:
No palpable pulsations or thrills

22. Auscultation:
Normal S1 and S2
No additional heart sounds
No murmurs, rub or gallop

23. Chest examination
Inspection:
No scars or sinuses or pigmentation
Palpation:
No tenderness
Normal TVF

24. Percussion:
Normal lung resonance
Upper border of the liver in the 5th
MCL
Auscultation:
Normal vesicular breathing
No wheezes or crepitations
No bilateral basal crepitations

25. Abdominal examination
Inspection:
No pigmentation, scratching marks or
sinuses
Palpation:
Superficial palpation:
No rigidity, tenderness or rebound
tenderness.
No superficial masses.

26. Deep palpation:
No palpable organomegaly.
Percussion:
No detectable ascites
Auscultation:
Audible intestinal sounds

27. Neurological examination
Intact cranial nerves.
Normal tone, power and reflexes.
Intact sensation.
Normal coordination.

28. Joint examination
Normal range of movement of all joints.
No redness or tenderness of any joints.

29. Lymph node examination
 No cervical, axillary or inguinal
lymphadenopathy.

30. Musculoskeletal examination
 No sternal tenderness.

31. INVESTIGATIONS

32. LABS

33. ESR
FIRST
HOUR :
52
SECOND
HOUR: 89

34. CBC
TLC 7.9
RBC’S 3.86
Hemoglobin 10.1
Haematocrit 30.9
M.C.V 79.9
M.C.H 26
M.C.H.C 32.6
RDW 16.5
PLATELETS COUNT 129

35.  Mild microcytic hypochromic anemia.
 RBCs show anisocytosis.
 Mild thrombocytopenia.

36. Coagulation profile
 PT : 23.8
 PC : 31.3 %
 INR: 1.88
 PTT: 38 ( 28-40 sec.)

37. Chemistry
BIL-T 1.24 Phosphorus 3
BIL-D 0.56 LDH 369
ALAT 33
(135-225)
AST 40
Albumin 3.6
Na 143
TGs 89 K 3.8
Cholesterol 188 T.Ptn 6.2
Urea 28 Alb 3.3
Creatinine 0.9 FBS 157
Calcium 8.7

38. Urine analysis
Color : yellow Pus cells : 8-10
Reaction: Acidic RBCs : 10-15
Crystals : Nil
Sp.gravity : 1015
Casts : Nil
Proteins : + Epithilial cells: Nil
Sugar : Nil
Acetone : Nil
Bile pigment : Nil

39. Immune profile
 ANA : +ve speckled and nucleolar
 C4 : 39.9 ( 10-40)
 C3 : 159 (90-180)
 Anti-ds DNA : Pending
 ANCA : Pending

40.  Lupus anticoagulant : 133
 Anticardiolipin : Pending
 Anti-B2-glycoprotein 1 IgG AM screen :
 56 (Up to 10 )

41.  Protein C : 37 ( 82-110)
 Protein S: 61 ( 71-113)

42. Tumor markers
 AFP : 2.5
 CA 15-5 : Pending
 CA19-9 : Pending
 CA125 : Pending

43. IMAGING

44. Duplex

47. Ultrasound


48. CT Neck

50. CT chest

52. CT abdomen