What is the appropriate management for a 76-year-old male's post-thrombectomy pain and pneumonia?

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Differential Diagnosis for Post-Op Pain in a 76-Year-Old Male

Single Most Likely Diagnosis

  • Surgical site hematoma or seroma: Given the patient's recent thrombectomy and the presence of hardening around the surgical site, a hematoma or seroma is a plausible explanation for the post-op pain. The patient's reports of pain when walking and the physical assessment findings support this diagnosis.

Other Likely Diagnoses

  • Deep vein thrombosis (DVT): Although the patient is on Eliquis, DVT is still a possible complication, especially given the patient's recent surgery and history of PE. The hardening around the surgical site could be related to a DVT.
  • Wound infection: Despite the lack of signs of infection, such as fever or purulent discharge, wound infection is still a possible diagnosis, especially if the patient has not been taking his prescribed pain medication (Tylenol) and has been experiencing pain.
  • Pulmonary embolism (PE) recurrence: Given the patient's history of PE and recent surgery, a recurrence of PE is possible, although the chest X-ray suggests pneumonia rather than PE.

Do Not Miss Diagnoses

  • Bleeding or hemorrhage: Although the patient denies bleeding, it is essential to consider the possibility of internal bleeding, especially given the patient's anticoagulation therapy (Eliquis). A bleeding complication could be life-threatening if not promptly addressed.
  • Sepsis: Although the patient denies fever, chills, or other signs of sepsis, it is crucial to consider this diagnosis, especially if the patient has a wound infection or pneumonia. Sepsis can be life-threatening if not promptly treated.

Rare Diagnoses

  • Compartment syndrome: This is a rare but possible complication of surgery, especially if the patient has a hematoma or other swelling in the affected limb. Compartment syndrome can lead to serious complications, including nerve damage and limb loss, if not promptly treated.
  • Nerve injury: The patient's reports of pain when walking and hardening around the surgical site could be related to a nerve injury, although this is a less likely diagnosis. Nerve injuries can be challenging to diagnose and treat, and prompt recognition is essential to prevent long-term complications.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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