A Bruise–Part I

Short post based on a real call.  Something to get the brain juices going a tiny bit.

You were watching the basketball finals in a gymnasium.  Both teams had played great, the game had ended and you were just about to leave when you notice a lady on the ground by the bleachers.  You decided to ask if she’s doing okay.

You:  “Hi, are you all right?”

Lady:  “Yeah…I just slipped and fell down the bleachers.  My leg is sore though.”

You:  “I’m an off duty paramedic, would you like me to take a look?”

Lady:  “Sure thing.”

The lady with some help from her husband stands up and sits on the bleachers.  You find out that she didn’t hit her head or lose consciousness and that she placed her hands out as she fell.  You notice that she’s a lady with a bigger build, easily 230lbs at a height of about 5’5.  She seems like a nice person and is very polite.

Lady:  “I’m so clumsy, I can’t believe I just fell.  I hurt my left ankle last week.”

You:  “Oh, that’s no good.  I suppose this isn’t the best way to finish the evening.”

You roll the lady’s pants up, you are greeted by legs that are quite edematous and there appears to be some varicose veins.  The veins bulge out at you and you can make out exactly where the valves are all located.

Lady:  “It’s just the right leg, it’s kind of sore in the lower calf by the ankle.”

You notice some bruising had started to form around the area.  There are good pulses and movement, no looseness of the ankle joint.  You compare the injured leg to the uninjured and the injured one was definitely a bit more swollen.  Despite that, there doesn’t seem to be any significant injury.

You:  “Your legs are a bit swollen, are your legs normally like this?”

Lady:  “Yes, it’s always been like this.”

You:  “Do you use pressure dressings for the swelling?”

Lady:  “No.”

You:  “I notice you have some swollen veins here, are you diagnosed with varicose veins?”

Lady:  “No, I’ve never talked to my doctor about it.”

You further examine the injured area and notice her right calf is quite hard compared to her uninjured side.  The lady says it is very tender over the hematoma and it worsens quite a bit when she walks (uses her gastrocnemius and soleus muscles).  The lady says she has had no other injuries to that leg before.  You are curious about her swollen legs and inquire if she’s had any heart conditions (for example CHF), diabetes, or any other medical conditions.  She denies any of the above conditions but says she’s had cholecystitis, has mildly high blood pressure and that she’s had a minor stroke before in the past from a clot.

You:  “Did the doctor say what caused the clot?”

Lady:  “Yeah, it was because I was on the pill.  I’ve stopped taking the pill ever since.”

You:  “Do you take aspirin?”

Lady:  “Not regularly, it’s not prescribed to me”

You make a final note that she’s not allergic to anything and that she’s not taking any medications aside from aspirin occasionally and tylenol for her left ankle injury last week.  Her vitals are normal.  Now you’ve gotten to the part in your patient assessment where you come up with a treatment plan.  It seems like a simple case.  Patient accidentally slipped and fell down two flights of bleachers.  She did not hit her head and did not lose consciousness from the incident.  Only injury noted is the hematoma forming on her right calf, which is hard on palpation.  Looks like a bruise.  Yet you are slightly hesitant to tell her to go home  and just put ice on her leg (or maybe you’re not).  Why is that?  What are some possible concerns floating through your head?  What would the best treatment plan be?  

Feel free to post what you think in the comments section, would love to hear your thoughts.  I will follow this  up with a second post.

Cheers

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Comments
11 Responses to “A Bruise–Part I”
  1. unbound says:

    Possible that she has DVT and there is potential for a clot to form and cause a pulmonary embolism?

  2. Chris Reimer says:

    My first thought is DVT caused by the ankle injury and exacerbated by the current fall. Call for a car to take her in to have the leg scanned and let them make the final determination. I would not let her go home…..
    Just my $.02

  3. Kevin says:

    If you have localized swelling after an injury then as you guessed it could be a hematoma, or possibly an MSK injury (fracture,strain,sprain). However you always have to worry about the potential for compartment syndrome and keep a close eye for symptom development if she has ongoing swelling. Having venous insufficiency as she does, and a history of hypercoagulability means you’d worry about a DVT, but that would be strange for it to immediately develop after an injury.

    Depending on the exam findings, she might have earned herself a trip to the ER for imaging studies to rule out the above problems. Is it the ankle that she injured, or her calf? It sounds more like she injured her ankle, which means the calf findings are potentially an unrelated finding. It could be more likely to be a DVT if she had localized swelling, tenderness, erythema etc.

    • PocketMedic says:

      As always good thoughts K 🙂 on assessment it was more calf than ankle, it was further up the calf than where the ankle joint is

      Sent from iphone

  4. Kevin says:

    Also, having a stroke after being on OCPs is a little strange. If she hasn’t already had it, she should have a workup for blood clotting disorders and possibly an echocardiogram to look for a hole in her heart (called a patent foramen ovale).She may need to be on permanent anticoagulation, or she may already be on something like warfarin and forgot to mention it.

    • PocketMedic says:

      I remember asking about blood thinners and she denied. May i ask why it’s strange having a stroke after being on OCPs as OCPs are known to form clots

      Sent from iphone

      • Kevin says:

        OCPs are known to be pro-thrombotic but:

        1) the majority of people on OCPs still don’t get clotting problems, so if you are one of the unfortunate ones who do, it makes you worry that they already had an underlying problem that was worsened by the birth control. The exception to this would be if they had other risks, such as a recent long flight, surgery, malignancy, or if they’re a smoker > 35 years of age. Obesity is a risk factor too, so i’m not saying she necessarily has anything else going on, but it’s a good idea to check. This is still pretty controversial. But I’m on the side that screening should be done. Up to 10% of Caucasians have some form of thrombophilia, most are undiagnosed.

        2) If you do get clotting problems from OCPs they are usually venous clots. If she had a stroke then it means either she had a clot in an artery (this would be unusual and warrants a workup), or she had a DVT that made its way to the left side of the heart via a hole in the heart, and then up into the brain. Being on birth control I’m assuming she’s at least under 50, which all together makes her story very concerning for having a stroke on OCPs.

  5. Hello!

    What I would have done. (Apart from my service being very different from yours ,but this is what I would do)

    As she fell down, we take it as a trauma in Brazil, so we have two options, emergency ambulance, or non emergency ambulance, the second one would be the choice,

    Due to the fall, and the previous health condition of the patient, I would encourage her to go to the hospital, mostly due to the possible fracture (although I don’t know long has it been since she fell down, because as we know, it might not hurt now, but in a couple of hours she might don’t even be able to put her feet on the ground),

    But yes, as our assessment is not as good as yours, the only thing I could do for the patient is physical inspection, and just take her to the hospital (which would probably get an X-Ray) and here in Brazil, they might even diagnose her if she has or not Diabetes, and take a look at her left ankle that was already hurting.

    Thank you!
    Cyrus Soltani Manjaterra
    Mogi Mirim Fire Department, São Paulo, Brazil

  6. Bobs says:

    Would love to see the follow up on this!

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  1. […] been meaning to write a follow up post on my last post:  A Bruise–Part I, but due to my delirious nature at the moment and my inability to think, I will write it another […]



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