Differential Diagnosis
The patient presents with post-operative pain, hardening around the surgical site, and a cough with mucus after a thrombectomy for pulmonary embolism (PE) removal. The following differential diagnoses are considered:
- Single Most Likely Diagnosis
- Surgical site hematoma or seroma: The patient reports hardening around the surgical site, which could be indicative of a hematoma or seroma. The lack of signs of infection or bleeding and the presence of tenderness support this diagnosis.
- Other Likely Diagnoses
- Pulmonary complications (atelectasis or pneumonia): The chest X-ray shows right lower lobe pneumonia, which could be contributing to the patient's cough and post-operative pain.
- Deep vein thrombosis (DVT): Although the patient is on Eliquis, the recent surgery and immobility increase the risk of DVT, which could cause pain and hardening in the affected limb.
- Wound infection: Although the patient denies fever and chills, a wound infection could still be present, especially if it is in the early stages.
- Do Not Miss Diagnoses
- Bleeding or hemorrhage: The patient is on anticoagulation therapy (Eliquis), which increases the risk of bleeding. Although the patient denies bleeding, it is essential to monitor for signs of hemorrhage.
- Pulmonary embolism (recurrence): The patient recently had a PE, and the presence of a new cough and post-operative pain could be indicative of a recurrent PE.
- Sepsis: Although the patient denies fever and chills, sepsis could still be present, especially if it is in the early stages.
- Rare Diagnoses
- Compartment syndrome: The hardening around the surgical site could be indicative of compartment syndrome, although this is less likely given the lack of other symptoms such as paresthesia or pallor.
- Nerve injury: The patient's pain and hardening around the surgical site could be indicative of a nerve injury, although this is less likely given the lack of other symptoms such as numbness or tingling.
SOAP Note
S - The patient is a 76-year-old male who presents with post-operative pain, hardening around the surgical site, and a cough with mucus after a thrombectomy for PE removal. O - The physical assessment reveals a 1cm area of hardening around the 0.5cm surgical site, tenderness, and no signs of infection or bleeding. The chest X-ray shows right lower lobe pneumonia. A - The differential diagnoses include surgical site hematoma or seroma, pulmonary complications, DVT, wound infection, bleeding or hemorrhage, recurrent PE, sepsis, compartment syndrome, and nerve injury. P - The patient will be monitored for signs of bleeding, infection, and pulmonary complications. The patient will be encouraged to take Tylenol for pain management, and the Eliquis will be continued. A follow-up chest X-ray will be ordered to monitor the pneumonia, and the patient will be referred to a wound care specialist to evaluate the surgical site.