Flank Pain Quiz

Hematology

Case Report of a Patient Presenting with ACUTE FLANK PAIN

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Hematology

Symptoms

A female in her 40s, with a history of heavy smoking presented to the emergency department with a 6-hour history of paraesthesia and unilateral left-sided calf swelling. Two hours after the onset of swelling, she developed severe left-sided flank pain, which required multiple doses of IV morphinefor relief. The patient's medical history included multiple recent admissions with a left-sided tubo-ovarian abscess, culminating in an emergency laparotomy, with a 1-day intensive therapy unit admission post-surgery. Following discharge the patient experienced a significant decline in her mobility levels.

Mild hypotension (91/60)

Low-grade pyrexia (37.7 °C)

Haemodynamically stable

Left-sided renal angle tenderness

Left calf was also visibly swollen, with pitting oedema to mid-shin, but was non-tender on palpation

Hematology

Clinical Investigations

An interim CT arterial portography revealed highly suspicious acute/subacute DVT with a tongue of thrombus extending from left common femoral vein into lower inferior vena cava.

Leucocytosis (18.7) with neutrophilia (12.7).

Urine dipstick was negative.

Initial coagulation studies were sent for a repeat as haemolysed. Shortly after, D-dimer was reported at 3,969.

Additional CT findings included a highly suspicious right lower lobe pulmonary embolism.

The patient was subsequently admitted under the medical team and treatment dose anticoagulation was initiated with tinzaparin.

An interim CT arterial...

Urine dipstick...

Initial coagulation studies...

The patient was...

Leucocytosis (18.7)...

Highly suspicious right...

Hematology

What is the most likely diagnosis for a patient presenting with acute left flank pain, extensive left-sided venous thrombi, and left-sided pulmonary embolism?

Renal colic

Deep vein thrombosis secondary to May-Thurner Syndrome

Nephrolithiasis with secondary venous thromboembolism

Aortic dissection with secondary thrombus formation

Hematology

Which imaging modality would you prioritise to confirm the diagnosis of May-Thurner Syndrome in a patient with suspected extensive left-sided venous thrombi?

Doppler ultrasound of the lower extremities

Magnetic resonance imaging (MRI) of the pelvis

CT venography of the pelvis and lower extremities

Contrast-enhanced ultrasound of the abdomen

Hematology

Which of the following factors would most influence your decision to perform an urgent intervention if bilateral pulmonary emboli were present?

Patient’s age

Severity of the emboli and haemodynamic instability

History of smoking

Presence of a family history of DVT

Hematology

If a patient with May-Thurner Syndrome and pulmonary emboli is haemodynamically unstable, which of the following would be the most appropriate next step?

Immediately transition to oral anticoagulants

Administer low-dose anticoagulation and monitor closely

Initiatiate IV heparin while preparing for potential intervention

Urgent thrombolysis or thrombectomy

Hematology

Which of the following factors would most influence your decision to perform an urgent intervention if bilateral pulmonary emboli were present?

Patient’s age

Severity of the emboli and haemodynamic instability

History of smoking

Presence of a family history of DVT

Hematology

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