Patient: On January 13, 2010, swelling and pain in the lower leg of the right lower extremity was found, and was examined by the county Chinese hospital and found to be a venous thrombosis of the right lower extremity. Then was hospitalized (injection), the condition was relieved after a week of hospitalization, the swelling disappeared, still some pain, then was prescribed some western medicine and went home to take medicine. Later, I found pain in my thighs, and I went to a Chinese doctor to take a few pairs of herbal medicines, and now I have developed a strong chest congestion and other symptoms. I would like to ask you to make a diagnosis and receive your treatment Laboratory and examination results: Last hospital visit.
Doctor: The swelling of the thigh indicates that the blood clot is spreading upward, and the appearance of chest tightness may have the occurrence of pulmonary embolism, so don’t be careless and go to the hospital again without delay. Remember.
Patient: Hello Director Qin: Are you still online now, the test results are out, would love to ask for your help
Patient: Hello Professor Qin: I am sending you the results of the examination, please take some time to help diagnose: 1.
1.Diagnostic ultrasound results: The right femoral vein and N vein are widened in the inner diameter of the official cavity, and medium-intensity echogenic filling is seen. The left femoral vein shows clear, the internal transmissive sound can be, after the probe local pressure, the official cavity disappears, CDFI shows: the blood flow is spontaneous, after calm breathing and lack of action, no obvious reflux signal S. The left N vein shows clear, after calm breathing and after squeezing the calf are not obvious reflux. Diagnostic opinion: right femoral vein and N vein thrombosis.
2, CT diagnostic results: left lower pneumonia, bilateral pleural effusion (small amount) .
3, ECG diagnostic results: sinus rhythm, high voltage on the left ventricular surface, ST-T changes, please give Professor Qin a diagnosis. Thank you.
Patient: Hello Professor Qin: We are going to see you tomorrow (February 16), we will take the bus at 5:00 am and try to get to work at 8:00 am. Or you can arrange a staff in your department, thank you.
Doctor: Don’t worry, there is a doctor on duty in my department in Spring.
Patient: Hello Professor Qin: Thank you for your support and patience. The patient has been admitted to your department on the morning of February 16, bed number 9, please be able to give a diagnosis. Thank you.
Doctor: Please don’t worry.
Patient: Hello, Professor Qin: I am sending you the patient’s test results on March 24, and hope you can take some time out of your busy schedule to make a diagnosis. The patient’s recent test results are: the wall of the right common femoral and deep femoral ducts are poorly defined, with some solid echogenicity, some of which can be compressed, and CDFI: some blood flow is visible, with 38% and 25% recanalization. The saphenous vein was normal in its course and there was blood flow within it. The right superficial femoral and N veins are dilated, with indistinct walls that cannot be compressed, solid echogenicity, CDFI: punctate blood flow signal, recanalization less than 10%.
The right calf muscle level is indistinct, deep veins are dilated with hypoechoic masses that cannot be compressed, CDFI: point loaded blood flow. Based on the current patient’s symptoms, what is the best information option and can surgical treatment be performed. The patient is now back in Qufu and is just recuperating at home, can you give a prescription. Thank you.
Doctor: At present, venous thrombosis does not require surgery, but medication. The treatment is more effective.
Patient: Hello, Professor Qin: My father’s right vein thrombosis is basically stable, and he has not taken any medication for about two months. My father went to your hospital again today (June 12) for a review, and the ultrasound description is as follows: there are common femoral and deep femoral vessels with poorly defined walls and small solid echogenicity within, most of which can be compressed, CDFI: most of the blood flow, recanalization 40-65%, 85%. The saphenous vein was normal in its course and had blood flow within it. The right superficial femoral and N veins are dilated, with indistinct walls that cannot be compressed, solid echogenicity, CDFI: punctate flow signal, recanalization <10%, and abundant flow in the surrounding collateral branches. The muscle layer of the right calf is unclear, the anterior tibial, posterior tibial, peroneal and intermuscular veins are not dilated, there is a small amount of solid echogenicity within the attached wall locally, basically can be compressed, CDFI: blood flow is basically filled. In response to the results of this examination, you see how treatment needs to be carried out. Our family would like to express our deep gratitude for the help you have given us and wish you all the best and success.
Doctor: Good recovery, superficial femoral vein is slightly worse, but there is no big problem, oral warfarin is not available, other drugs can generally be used without it.
Patient: Hello Professor Qin: At present the patient is not taking medication, you see whether you still need to eat a period of time on the Chinese medicine, or you give a few pairs of prescription. Also if you take warfarin, how to take it, please tell. I wish you good health and all the best.
Doctor: Take pulse and blood capsule for 2 months.
Patient: Hello, Professor Qin: Thank you for your selfless help. The pulse and blood capsule you recommended is not available in our city of Qufu, can you prescribe another medicine. I wish you good health and all the best.
Doctor: Thrombolytic capsules can also be used instead.