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Embed code for: Discharge Summary - MN00087674
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DISCHARGE SUMMARY Joondalup Health Campus Cnr Grand Blvd & Shenton Ave JOONDALUP WA 6027 Tel: (08) 9400 9400 | Fax: (08) 9400 9054 JHC MRN: MN00087674 NAME: SCOTT CAREY ADDRESS: 34 KALBARRI AVENUE YANCHEP WA 6035 Ph 0432 118 470 GP NAME: Medical Centre Yanchep Yanchep Medical Centre, 1/5 Village Row, YANCHEP, WA 6035 ADMISSION NO: AN11290301 Date of Birth: 14/04/1972 (44 years) Date Admitted: 14/10/2016 Date Discharged: 14/10/2016 Consultant: Hung Nguyen Summary Status: Version 1 - Complete Completed By: Quach, William (Registrar) on 17/10/2016 PRINCIPAL DIAGNOSIS (AT DISCHARGE) Principal Diagnosis; General > Deep vein thrombosis (DVT) of Left Leg PAST HISTORY Previous Medical History; Recurrent VTE - Managed by SCGH Haematology Respiratory > Asthma INVESTIGATIONS DUPLEX DOPPLER VENOUS ULTRASOUND LEFT LOWER LIMB Clinical Details: Hypercoagulable prior pulmonary embolism. ?DVT. ?Extent. Findings: There is extensive venous thrombosis in the left lower limb, involving most of the femoral and popliteal veins. The DVT extends throughout the popliteal vein and the popliteal fossa, and then proximally through almost the entire femoral vein, proximally to a level 2cm below the groin crease. There is no extension above the inguinal ligament into the common femoral or iliac vein. There is occlusive thrombus in the short saphenous vein from the knee crease over a length of 30cm inferiorly. Comment: Extensive venous thrombosis of the left popliteal and femoral veins extending proximally to a level 2cm below the groin crease. PROGRESS & MANAGEMENT Progress & Management; Mr Scott is a 44 year old gentleman who presents with lower limb swelling progressing over the last week with an associated overlying rash. He had Seen his GP who had prescribed a topical steroid due to the itch associated to the rash with some relief and partial resolution of the rash however the lower limb swelling persisted. Given Mr Carey's previous history of multiple DVT there was some index of suspiscion for a DVT despite him being on twice daily 100mg subcutaneous enoxaparin. Mr Carey appeared systemically well. The swollen left lower limb did not have the typical appearance of DVT nor cellulitis. IV flucloxacillin was given to cover for a cellulitis whilst awaiting doppler ultrasound scan. The Doppler USS scan revealed thrombosis as documented in the included report. After discussion with the Haematology registrar on call at SCGH, it was proposed that enoxaparin could be continued and titrated to anti-Xa levels taken 4 hours post dosage or the use of the Non-warfarin Oral Anticoagulants could be used instead of enoxaparin. After discussion with the patient, Scott was agreeable to use Rivaroxiban. There was planned haematology outpatient review at SCGH on the 19th of October at 9am which would serve to follow up from this admission. Mental State Exam on Discharge; FUTURE MANAGEMENT PLAN Follow up at SCGH haemotology outpatient haemostasis clinic on 19th October 2016 as prior arrangements. PARTICIPANTS Hung NGUYEN Attending Doctor - General Medicine Medical Centre YANCHEP GP Yanchep Medical Centre, 1/5 Village Row, YANCHEP, WA 6035 p: 08 9562 8100 f: 08 9562 8188 SCOTT CAREY 14/04/1972 MN00087674 AN11290301 COMPLETED BY Quach, William on 17/10/2016 PRINTED BY Quach, William on 17/10/2016 Joondalup Hospital Pty Ltd ABN 61 106 723 193 trading as Joondalup Health Campus Page 1 of 1