Detailed Treatment Process
Female, 61 years old, persistent pain after varicose vein surgery The following is an ultrasound report Hospital A Cardiovascular Ultrasound Examination Report Gender: Female, Age: 61 years Date of referral: August 15 of the first year Clinical diagnosis: Swelling and pain in the left lower limb Examination site: Left lower limb veins Ultrasound description Left lower limb veins: The left common femoral vein, superficial femoral vein, and popliteal vein show normal course, with no abnormal echoes inside. The lumen can be completely closed under probe compression. Color flow filling is continuous without defects. The left great saphenous vein is tortuous and dilated. Solid low echoes are visible in the local lumen of the calf segment, with no definite blood flow signal. The lumen cannot be completely closed under probe compression. Ultrasound impression The left common femoral vein, superficial femoral vein, and popliteal vein have unobstructed blood flow Local thrombosis in the left great saphenous vein Examination date: August 15 of the first year
Inpatient treatment at Hospital B. The following is the discharge summary Department: East Campus Vascular Surgery Inpatient Ward Admission date: 08:40 on November 8 of the first year Discharge date: November 12 of the first year 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 local redness and swelling for 2 years Physical examination: T 36.8℃ 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. Slight swelling of the left lower limb. Arterial palpation: left femoral ++, popliteal ++, dorsalis pedis ++, posterior tibial ++; right femoral ++, popliteal ++, dorsalis pedis ++, posterior tibial ++ Main examination results November 8 of the first year complete blood count (CBC) report: white blood cell count 4.12 × 10⁹/L, hemoglobin 113 g/L, neutrophil % 60.9%, platelet count 120 × 10⁹/L. Coagulation series test report: prothrombin time 9.7 seconds L, fibrinogen 2.99 g/L, prothrombin INR 0.88 R, thrombin time 16.3 s. Glucose GLU, renal function, electrolytes, liver function test report: sodium 142 mmol/L, potassium 3.8 mmol/L, chloride 108 mmol/L, creatinine 71.5 umol/L, urea nitrogen 5.30 mmol/L, uric acid 151.00 umol/L, albumin 45.5 g/L, alanine aminotransferase 18.0 IU/L, aspartate aminotransferase 29.0 IU/L, total bilirubin 9.30 umol/L, direct bilirubin 3.2 umol/L, fasting blood glucose 6.01 mmol/L. Special examinations and important consultations (with examination dates and numbers noted) Electrocardiogram: no abnormalities Hospital course and treatment outcomes (with surgery dates and names noted; blood transfusion volume and resuscitation status) After admission, the patient completed various examinations and preoperative preparations. On November (specific day not noted in the original record) left lower limb varicose vein stripping + laser ablation was performed under general anesthesia. Intraoperatively, dilated superficial veins were noted in the left lower leg with local clustering, mild pigmentation, and severe adhesion of some vessels to the skin. The operation went smoothly. Postoperative symptomatic supportive treatment was given. The patient recovered well and was discharged. Complications: none Condition at discharge (symptoms and signs) The patient had no obvious discomfort Physical examination: alert, normal breathing, clean and dry left lower limb wounds without exudate, no swelling in the left lower limb Treatment outcome: cured November 12 of the first year
In the expense list for this hospitalization, the surgery-related items were: 1. High ligation + stripping of the great saphenous vein, 2. Great saphenous vein closure After the operation, the patient had multiple outpatient follow-ups on November 19, November 29, December 3, December 24 of the first year, and January 7 of the following year. The outpatient records repeatedly documented the patient's chief complaint of leg pain The following is the ultrasound report from Hospital C Gender: Female, Age: 62 years Ward: Ward 4 Examination date: 14:59:39 on January 15 of the second year Findings: Right common carotid artery inner diameter 5.7 mm, IMT 0.7 mm, peak velocity 0.82 m/s, RI 0.67. Internal carotid artery inner diameter 3.8 mm, RI 0.53. External carotid artery inner diameter 3.2 mm. Left common carotid artery inner diameter 5.7 mm, IMT 0.7 mm, peak velocity 1.07 m/s, RI 0.66. Internal carotid artery inner diameter 4.6 mm, RI 0.51. External carotid artery inner diameter 3.3 mm. Right vertebral artery inner diameter 3.3 mm, RI 0.56. Left vertebral artery inner diameter 3.0 mm, RI 0.54. CDFI showed unobstructed blood flow in bilateral carotid and vertebral arteries, normal direction, and basically normal flow velocity curves. Right common femoral artery inner 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 inner 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 in original) mm. CDFI showed unobstructed blood flow in the above arteries with basically normal flow velocity curves. Substantial echoes seen in the left popliteal vein and posterior tibial vein. No obvious color flow on CDFI. Impression: Unobstructed blood flow in carotid and vertebral arteries, unobstructed blood flow in bilateral lower limb arteries Thrombosis in the left popliteal vein and posterior tibial vein
The following is the CTA examination report from Hospital C Ward: Ward 4 Clinical diagnosis: Left lower limb ischemia; left lower limb arterial embolism; hypertension Referring physician request: Preoperative examination Examination time: 09:27:50 on January 16 of the second year Report writing time: 13:19:52 on January 17 of the second year Report review time: 14:22:53 on January 17 of the second year Examination site and name: Vessels Examination method: Bilateral lower limb arterial CTA Radiological findings: Mild mural calcification in the lower abdominal aorta. Bilateral posterior tibial arteries poorly visualized. The remaining bilateral lower limb arteries and branches are well displayed with normal course, no stenosis, filling defects, or dilatation/displacement. Radiological diagnosis: Bilateral posterior tibial arteries poorly visualized. Please correlate with clinical findings.
Department: East Campus Vascular Surgery Inpatient Ward Admission date: 14:43 on February 18 of the second year Discharge date: April 27 of the second year 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: February 22 of the second year coagulation series test report: prothrombin time 20.8 seconds H, fibrinogen 2.88 g/L, prothrombin INR 1.85 RH, thrombin time 14.5 s, activated partial thromboplastin time 34.1 s. February 25 of the second year prothrombin time (PT) report: prothrombin time 18.1 seconds H, prothrombin INR 1.47 RH. Carbohydrate antigen 199 report: carbohydrate antigen 199 8.30 U/mL February 26 of the second year CA50 report: CA50 8.2 U/mL February 28 of the second year fecal occult blood test report: fecal occult blood test negative March 6 of the second year coagulation series test report: prothrombin time 11.8 seconds, fibrinogen 2.88 g/L, prothrombin INR 1.04 R, thrombin time 14.2 s, activated partial thromboplastin time 27.8 s March 19 of the second year prothrombin time (PT) report: prothrombin time 10.2 seconds, prothrombin INR 0.92 R. March 25 of the second year prothrombin time (PT) report: prothrombin time 11.8 seconds, prothrombin INR 1.02 R. March 29 of the second year prothrombin time (PT) report: prothrombin time 12.1 seconds, prothrombin INR 1.06 R. April 8 of the second year prothrombin time (PT) report: prothrombin time 11.9 seconds, prothrombin INR 1.04 R. Special examinations and important consultations (with examination dates and numbers noted): Ultrasound (April 25 of the second year): Left popliteal vein and posterior tibial vein walls slightly rough. Left lower limb deep veins patent. 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 indicates osteoporosis in the left femur Left ankle MRI: Fluid in the left ankle posterior tibial tendon and flexor digitorum longus tendon sheaths, mild fluid around the ankle, left ankle joint effusion, mild soft tissue edema around the ankle Lumbar MRI: Degenerative changes in the lumbar spine, small hemangioma in L2 vertebral body, L2/3 disc bulge, lumbar disc degeneration Ultrasound (February 27 of the second year): Left lower limb deep veins patent Hospital course and treatment outcomes (with surgery dates and names noted; blood transfusion volume and resuscitation status): After admission, relevant examinations were completed, including lower limb venous ultrasound, lumbar MRI, ankle X-ray, etc. Treatment included vasodilators, blood-activating therapy, diuretics for swelling reduction, pain relief, and calcium supplementation. The patient’s general condition is now stable and she is discharged. Complications: none Condition at discharge (symptoms and signs): The patient reports persistent pain in the left lower limb, more pronounced on walking, though slightly improved compared to before Physical examination: Alert, normal breathing. No redness or swelling in the left lower limb. Obvious tenderness still present in the mid-to-lower pretibial area of the calf. Edema basically resolved. Normal skin temperature and color. Palpable dorsalis pedis artery pulse. Post-discharge medications and recommendations: 1. Follow-up at vascular surgery clinic. 2. Medications: spironolactone 1 bottle; calcitriol 2 boxes. Treatment outcome: improved April 27 of the second year
The following is the ultrasound report from Hospital A Gender: Female, Age: 61 years Date of referral: May 15 of the second year Clinical diagnosis: Postoperative left lower limb varicose veins Examination site: Left lower limb veins Ultrasound description Left lower limb veins: The left common femoral vein, superficial femoral vein, and popliteal vein show normal course, with no abnormal echoes inside. The lumen can be completely closed under probe compression. Color flow filling is continuous without defects. No obvious main trunk of the great saphenous vein seen in the left lower limb Ultrasound impression The left common femoral vein, superficial femoral vein, and popliteal vein have unobstructed blood flow Postoperative changes after left great saphenous vein varicose vein surgery Examination date: May 15 of the second year
Afterward, the hospital provided the patient with some financial compensation