Detailed Treatment Process
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Female, 61 years old, with persistent pain after varicose vein surgery. The following is an ultrasound report. The following is an ultrasound report Hospital A Cardiovascular Ultrasound Examination Report Sex: Female, Age: 61 years Date of referral: August 15, Year 1 Clinical diagnosis: Swelling and pain in the left lower limb Examination site: Left lower limb veins Ultrasound findings Left lower limb veins: The left common femoral vein, superficial femoral vein, and popliteal vein showed normal course with no abnormal internal echoes. The lumen collapsed completely under probe compression, with continuous color Doppler filling and no defects. The left great saphenous vein was tortuous and dilated. In the calf segment, solid hypoechoic material filled part of the lumen, with no definite blood flow signal. The lumen did not collapse completely under probe compression. Ultrasound impression Patent blood flow in the left common femoral vein, superficial femoral vein, and popliteal vein. Local thrombosis in the left great saphenous vein. Examination date: August 15, Year 1
The patient received inpatient treatment at Hospital B. The following is the discharge summary. Department: East Campus Vascular Surgery Inpatient Unit Admission date: November 8, Year 1, 08:40 Discharge date: November 12, Year 1 Outpatient diagnosis: Left lower limb venous insufficiency, thrombophlebitis Admission diagnosis: Left lower limb venous insufficiency, thrombophlebitis Discharge diagnosis: Left lower limb venous insufficiency, thrombophlebitis Main symptoms and signs on admission Varicose subcutaneous veins in the left lower limb for 5 years, with recurrent localized redness and swelling for 2 years. Physical examination: T 36.8°C, P 80 beats/min, R 18 breaths/min, BP 110/76 mmHg. Obvious varicose superficial veins along the great saphenous vein in the left lower limb, with local clustering. Pigmentation in the pretibial area. Mild swelling of the left lower limb. Arterial pulses: left femoral ++, popliteal ++, dorsalis pedis ++, posterior tibial ++; right femoral ++, popliteal ++, dorsalis pedis ++, posterior tibial ++. Main examination results Year 1 November 8 CBC report: white blood cell count 4.12 × 10⁹/L, hemoglobin 113 g/L, neutrophils 60.9%, platelet count 120 × 10⁹/L. Coagulation profile: prothrombin time 9.7 s (L), fibrinogen 2.99 g/L, INR 0.88 (R), thrombin time 16.3 s. Glucose, renal function, electrolytes, and liver function: sodium 142 mmol/L, potassium 3.8 mmol/L, chloride 108 mmol/L, creatinine 71.5 μmol/L, urea nitrogen 5.30 mmol/L, uric acid 151.00 μmol/L, albumin 45.5 g/L, ALT 18.0 IU/L, AST 29.0 IU/L, total bilirubin 9.30 μmol/L, direct bilirubin 3.2 μmol/L, fasting blood glucose 6.01 mmol/L. Special examinations and important consultations (with dates and reference numbers) Electrocardiogram: no significant abnormalities. Hospital course and treatment outcome (including surgery dates, procedure names, blood transfusion volumes, and resuscitation details) After admission, the patient completed preoperative evaluation. On November (specific day not recorded) of Year 1, she underwent left lower limb varicose vein stripping plus laser ablation under general anesthesia. Intraoperatively, dilated superficial veins were noted in the left calf with local clustering, mild pigmentation, and severe adhesions between some vessels and skin. The procedure went smoothly. Postoperative symptomatic supportive care was provided. The patient recovered well and was discharged. Complications: none Condition at discharge (symptoms and signs) The patient reported no obvious discomfort. Physical examination: alert, normal breathing, clean and dry left lower limb surgical wounds without exudate, no swelling in the left lower limb. Treatment outcome: cured November 12, Year 1
In the hospitalization cost list for this admission, two items referred to the surgery: 1. high ligation and stripping of the great saphenous vein, 2. great saphenous vein closure. After discharge, the patient attended multiple outpatient follow-up visits on November 19, November 29, December 3, and December 24 of Year 1, and January 7 of the following year. The outpatient records repeatedly noted the patient’s complaints of leg pain. The following is an ultrasound report from Hospital C. Sex: Female, Age: 62 years Ward: Ward 4 Examination date: January 15, Year 2, 14:59:39 Findings: Right common carotid artery diameter 5.7 mm, IMT 0.7 mm, peak velocity 0.82 m/s, RI 0.67; internal carotid artery diameter 3.8 mm, RI 0.53; external carotid artery diameter 3.2 mm. Left common carotid artery diameter 5.7 mm, IMT 0.7 mm, peak velocity 1.07 m/s, RI 0.66; internal carotid artery diameter 4.6 mm, RI 0.51; external carotid artery diameter 3.3 mm. Right vertebral artery diameter 3.3 mm, RI 0.56; left vertebral artery diameter 3.0 mm, RI 0.54. CDFI showed patent flow in bilateral carotid and vertebral arteries with normal direction and essentially normal velocity waveforms. Right common femoral artery diameter 7.4 mm, superficial femoral artery 5.1 mm, deep femoral artery 4.8 mm, popliteal artery 4.0 mm, posterior tibial artery 2.8 mm. Left common femoral artery diameter 7.0 mm, superficial femoral artery 4.3 mm, deep femoral artery 5.1 mm, popliteal artery 4.0 mm, posterior tibial artery (value missing) mm. CDFI showed patent flow in the above arteries with essentially normal velocity waveforms. Substantial echoes were seen in the left popliteal vein and posterior tibial vein, with no obvious color flow on CDFI. Impression: Patent flow in carotid and vertebral arteries, patent flow in bilateral lower limb arteries. Thrombosis in the left popliteal vein and posterior tibial vein.
The following is a CTA report from Hospital C. Ward: Ward 4 Clinical diagnosis: Left lower limb ischemia; left lower limb arterial embolism; hypertension Requesting physician’s indication: preoperative evaluation Scan time: January 16, Year 2, 09:27:50 Report written: January 17, Year 2, 13:19:52 Report verified: January 17, Year 2, 14:22:53 Examination: Bilateral lower limb arterial CTA Radiological findings: Minor mural calcification in the lower abdominal aorta. Poor visualization of bilateral posterior tibial arteries. The remaining lower limb arteries and branches were well demonstrated with normal course, no stenosis, filling defects, or dilatation. Radiological diagnosis: Poor visualization of bilateral posterior tibial arteries. Please correlate with clinical findings.
Department: East Campus Vascular Surgery Inpatient Unit Admission date: February 18, Year 2, 14:43 Discharge date: April 27, Year 2 Outpatient diagnosis: Postoperative left lower limb varicose veins; left lower limb deep vein thrombosis Admission diagnosis: Postoperative left lower limb varicose veins; left lower limb deep vein thrombosis Discharge diagnosis: Postoperative left lower limb varicose veins; left popliteal vein thrombosis; left lower limb osteoporosis Main symptoms and signs on admission: 1. Female patient, 61 years old. 2. Admitted for “left lower limb pain and discomfort 3 months after varicose vein surgery.” Main examination results: Year 2 February 22 coagulation profile: prothrombin time 20.8 s (H), fibrinogen 2.88 g/L, INR 1.85 (RH), thrombin time 14.5 s, APTT 34.1 s. February 25 PT: prothrombin time 18.1 s (H), INR 1.47 (RH). CA19-9: 8.30 U/mL. February 26 CA50: 8.2 U/mL. February 28 fecal occult blood: negative. March 6 coagulation profile: prothrombin time 11.8 s, fibrinogen 2.88 g/L, INR 1.04 (R), thrombin time 14.2 s, APTT 27.8 s. March 19 PT: 10.2 s, INR 0.92 (R). March 25 PT: 11.8 s, INR 1.02 (R). March 29 PT: 12.1 s, INR 1.06 (R). April 8 PT: 11.9 s, INR 1.04 (R). Special examinations and important consultations (with dates): Ultrasound (April 25, Year 2): Slightly rough walls of the left popliteal and posterior tibial veins. Patent lumen in left lower limb deep veins. Electrocardiogram: normal. X-ray: Degenerative changes in the left ankle joint with mild osteoporosis; degenerative changes in the left tibia and fibula with mild local osteoporosis. Nuclear medicine bone density report: T-score indicated osteoporosis in the left femur. Left ankle MRI: Fluid in the posterior tibial tendon and long flexor digitorum tendon sheaths, mild fluid around the ankle, ankle joint effusion, and surrounding soft tissue edema. Lumbar MRI: Degenerative changes in the lumbar spine, small hemangioma in L2 vertebral body, L2/3 disc bulge, and lumbar disc degeneration. Ultrasound (February 27, Year 2): Patent lumen in left lower limb deep veins. Hospital course and treatment outcome (including surgery dates, procedure names, blood transfusion volumes, and resuscitation details): After admission, the patient completed relevant examinations including lower limb venous ultrasound, lumbar MRI, and ankle X-rays. She received treatment with vasodilators, blood-activating agents, diuretics for swelling reduction, analgesics, and calcium supplementation. Her general condition was stable, and she was discharged. Complications: none Condition at discharge (symptoms and signs): The patient reported persistent left lower limb pain, more noticeable on walking but slightly improved compared with before. Physical examination: alert, normal breathing, no redness or swelling in the left lower limb, persistent tenderness in the middle-to-lower pretibial area, edema largely resolved, normal skin temperature and color, palpable dorsalis pedis pulse. Discharge medications and recommendations: 1. Follow-up in vascular surgery clinic. 2. Medications: spironolactone 1 bottle; calcitriol 2 boxes. Treatment outcome: improved April 27, Year 2
The following is an ultrasound report from Hospital A. Sex: Female, Age: 61 years Date of referral: May 15, Year 2 Clinical diagnosis: Postoperative left lower limb varicose veins Examination site: Left lower limb veins Ultrasound findings Left lower limb veins: The left common femoral vein, superficial femoral vein, and popliteal vein showed normal course with no abnormal internal echoes. The lumen collapsed completely under probe compression, with continuous color Doppler filling and no defects. No obvious main trunk of the great saphenous vein was seen in the left lower limb. Ultrasound impression Patent blood flow in the left common femoral vein, superficial femoral vein, and popliteal vein. Status post great saphenous vein varicose treatment. Examination date: May 15, Year 2
The hospital later provided the patient with financial compensation.