Greeting
Good day, dear Professor Doctor …,
I would like to introduce Ms. Elisabeth Altmann to you now.
She is 57 years old, 166 cm tall and weighs approximately 88 kg. The body mass index (BMI) is 31.9 (obesity).
Current medical history
The patient presented after referral by her family doctor because of acute onset, progressive, dragging pain of the left lower leg that had been present for two days, radiating into the calf as well as into the sole of the foot .
She stated that she would rate the pain at rest at about 5 out of 10, while it increased to around 7 after movement.
In addition, there is a movement restriction due to pain; she can hardly bear weight on the affected leg, neither when walking nor when standing up. The pain improves with elevation.
There is shiny skin with a reddish-bluish discoloration, a hyperthermia as well as a difference in circumference between the legs. For about a year there have also been trophic changes in the form of an eczema present, presumably due to a venous disorder.
She has been taking an oral contraceptive (Jaz) for six months.
There is neither dyspnea nor chest pain.
The following were denied:
• swelling or a feeling of pressure behind the knee
• a well-demarcated, warm, erythematous area
• Ulcers, Malposition, Paresthesias or hypesthesia of the foot in the sense of a polyneuropathy as well as nail changes
• A history regarding thromboses, recent surgeries with prolonged immobility/ long-distance travel, coagulopathies, malignancies or cardiac diseases
• Chronically progressive pain, particularly after physical exertion
• Low back pain with radicular symptoms
The autonomic history
The autonomic history is unremarkable, apart from constipation.
The patient expresses a desire for weight reduction.
Pre-existing conditions
The following pre-existing conditions are known:
For about 20 years there have been varicose veins on the medial side of the left lower leg, milder on the right. There is a sensation of heaviness, so the patient frequently elevates her legs and wears compression stockings. Recently the symptoms have worsened. For cosmetic reasons she predominantly wears long trousers.
Arterial hypertension has been known for 12 years; the diagnosis was made incidentally during a hospital stay for a foot injury. Blood pressure values are mmHg adequately controlled, no consequential complications exist. The last ophthalmologist visit took place two years ago.
|
systolic (mmHg) |
diastolic (mmHg) |
Treatment |
|
|
Normal blood pressure |
< 120 |
< 70 |
– |
|
Elevated blood pressure |
120–139 |
70–89 |
+ |
There is a seborrheic eczema with scaling in the area of the eyebrows and behind the ears, worsened by psychological stress, cold exposure, and hyperhidrosis.
For eight years there has been a tendovaginitis of the left wrist due to overuse from computer work.
12 years ago the patient sustained a fracture in the area of the midfoot with accompanying ligament rupture. Initial X-rays showed no findings; the diagnosis was made two weeks later by MRI. The foot was immobilized with a special shoe, followed by physiotherapy. Since then there have been limitations with sporting activity.
Previous surgeries
About 20 years ago there was an ectopic pregnancy; a laparotomy with hysterectomy and right oophorectomy was performed, the course was uncomplicated.
Note: If a statement can be objectively confirmed by a medical examination – for example by visible scars – the indicative is appropriate. (No physical examination takes place in the specialist language examination.)
Gynecology
The patient has been in menopause for nine years; because of hot flashes and mood swings she has been taking the oral contraceptive Jaz on her gynecologist’s recommendation for six months.
Medications
• Votum plus 20/12,5 mg – 1-0-0
• Decoderm® cream – topical as needed
• Femoston for 6 months 1-0-0
• Ibuprofen 400 mg tab. – as needed
• Movicol® – as needed for constipation
Note: If a statement can be objectively confirmed by a physician’s observation – for example by a prescription – the indicative is appropriate.
Allergies
There is lactose intolerance with abdominal pain and diarrhea.
In addition, there is an amoxicillin allergy with urticaria.
Exposures
The patient reports smoking about 20 cigarettes daily for 30 years, corresponding to 20 pack-years, and she expresses the desire for smoking cessation.
She occasionally consumes wine or beer.
Drug use was denied.
Social history
The patient works in a tax office and has been married for the second time for 15 years. She lives with her nine-year-old foster son, who was diagnosed two weeks ago with Pediculosis capitis The treatment was carried out with Nyda® and a lice comb.
Family history
The patient reports that her father suffered for years from postprandial abdominal pain. Therapy with pantoprazole had no effect, and the colonoscopy was unremarkable. At the age of 75 he was diagnosed with mesenteric ischemia, from which he died a few days later.
Her mother is 70 years old and lives in a nursing home. She has varicose veins as well as coxarthrosis, for which a hip THA was implanted and, after a postoperative infection, replaced again. In addition, she has a coagulation disorder.
Suspected and differential diagnosis
In my assessment, the history — in particular the acute lower leg pain and the difference in leg circumference — is suggestive of a deep vein thrombosis (DVT). Risk factors in this case include obesity and nicotine abuse.
With intermittent claudication one expects exertion-dependent pain in the limb, improvement at rest, and a reduced walking distance. It is a chronic course with multiple risk factors for arteriosclerosis.
With a Superficial Thrombophlebitis local pain and a palpable, hardened venous cord as well as redness and increased warmth of the skin are to be expected.
With cellulitis or erysipelas one expects diffuse redness, warmth, swelling, and pressure tenderness of the skin.
In a ruptured Baker’s cyst one usually expects swelling in the popliteal fossa.
The post-thrombotic syndrome occurs when, after a deep vein thrombosis, chronic venous insufficiency develops due to persistent venous valve destruction and impaired venous return.
With a muscle strain (Muscle strain) local pain, pressure tenderness, and reduced load-bearing capacity are to be expected.
Diagnostic evaluation
If DVT is suspected, the patient should be admitted as an inpatient in order to initiate diagnostic and therapeutic measures immediately. There is a risk of embolism, so immediate evaluation and treatment should be considered.
Physical examination
After the history, a structured physical examination should be performed. This begins with recording the vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation and temperature), followed by inspection of the affected extremity with side-by-side comparison.
Skin changes such as pallor, swelling in the popliteal fossa, cyanosis, varicosities, edema and trophic disturbances as well as, where applicable, the characteristics of ulcers (location, size, borders, secretion, odor) should be assessed. In addition, attention should be paid to well-demarcated, warm erythematous areas.
Palpation is used to check peripheral pulses and capillary refill time as well as tenderness on pressure along the veins.
• Femoral artery: in the groin, approximately halfway between the anterior superior iliac spine and the pubic symphysis
• Popliteal artery: in the popliteal fossa with the knee slightly flexed, difficult to palpate
• Posterior tibial artery: behind the medial malleolus
• Dorsalis pedis artery: on the dorsum of the foot, lateral to the tendon of the extensor hallucis longus muscle
If edema is present, it should be checked whether it is pitting. Auscultation over the vessels can reveal pathological flow sounds (e.g., over the femoral artery).
Special examinations for suspected DVT:
• Homans’ sign: positive when passive dorsiflexion of the foot with the leg extended causes calf pain.
• Payr’s sign: positive when pressure with the fingers on the medial sole of the foot elicits tenderness.
• Meyer’s sign: positive when pressure along the great saphenous vein on the medial side of the lower leg elicits pain.
Laboratory tests
For further clarification, a complete blood count, CRP, ESR, D-dimers, coagulation status as well as electrolytes and renal function parameters (creatinine, urea, GFR) should be determined.
If the D-dimer test is positive or the clinical probability is high, the diagnosis of deep vein thrombosis or pulmonary embolism should be confirmed by venous compression sonography or computed tomography pulmonary angiography (CTPA).
Electrocardiogram
Classic ECG findings in pulmonary embolism are S waves in lead I as well as Q waves and negative T waves in lead III; together they form the typical S1Q3T3 pattern. In addition, sinus tachycardia is often present.
Compression sonography
In compression sonography the ultrasound probe is used to apply targeted pressure to the vein: a healthy vein is completely compressible, whereas a thrombosed vein cannot or only partially compress.
At the beginning a special contact gel is applied to the skin to improve transmission of the sound waves. The ultrasound probe is then moved over the affected vessel segments. The examination is painless and usually takes about 20 minutes.
Color duplex sonography is a noninvasive ultrasound examination that provides a color-coded depiction of vascular structures and blood flow.
This allows reliable detection of vascular stenoses, occlusions, or thromboses. In addition, blood flow direction and velocity can be assessed.
Computed tomographic pulmonary angiography
Multidetector CT pulmonary angiography (CTPA) has largely replaced ventilation–perfusion scintigraphy in the diagnosis of pulmonary embolism. Reasons include wide availability, rapid performance, and sufficient sensitivity and specificity to justify its use as a single test. It also allows evaluation of alternative diagnoses in many patients without evidence of pulmonary embolism.
CTPA can be combined with CT phlebography so that the diagnosis of both pulmonary embolism and deep vein thrombosis can be made with a single examination and a single contrast administration, although this is not performed routinely.
Venography
In venography (phlebography) access is obtained via a superficial vein, for examinations of the leg veins usually on the dorsum of the foot. Because no arterial puncture is required, there are generally lower access-related risks than with catheter-based arterial angiography.
Procedure and patient information:
„In this examination we make your veins visible on X‑rays using a contrast agent. For this we disinfect the skin and insert a small cannula into a superficial vein. We then inject an iodinated contrast agent and take several X‑ray images. During this you may briefly feel a warming sensation or a metallic taste. Please try to lie as still as possible during the images. If necessary we will ask you to change your position. At the end we remove the cannula and dress the puncture site with a bandage.
Please inform us beforehand about known contrast agent reactions, kidney or thyroid diseases, or a possible pregnancy. Possible complications include bruising, bleeding, phlebitis and contrast reactions; thromboses or kidney damage can occur rarely. In addition, the examination involves exposure to radiation
Compared with ultrasound, venography (gold standard) offers no additional advantages, but is more complex, carries a higher risk of complications (e.g. contrast reactions, thrombophlebitis) and involves radiation exposure. Therefore it is now used only in exceptional cases.
Echocardiography
In general, echocardiography is recommended routinely only in patients with severe hypoxemia or other signs of hemodynamic compromise.
Consultations
Cardiology, Internal Medicine
Treatment
• Outpatient therapy: in most patients with DVT and in low-risk patients with acute PE as safe as inpatient treatment
• Anticoagulation: mainstay of therapy, immediate start even when DVT/PE is suspected (prior to confirmatory diagnostics)
• Anticoagulation 3 months: reversible risk factors (low-risk group)
• Anticoagulation 6 months: idiopathic DVT or medical risk factors (intermediate-risk group)
• Severe hemodynamic compromise: indication for reperfusion procedures or surgical thrombectomy
• Compression stockings: reduces risk of post-thrombotic syndrome
direct oral anticoagulants (DOACs)
• Dabigatran (thrombin inhibitor), Rivaroxaban, Apixaban, Edoxaban (factor Xa inhibitors)
• Guideline recommendation: preferred in patients without active cancer
• Advantages: effective, safe, fixed dosing, no routine monitoring required
• Rivaroxaban dosing in acute DVT/PE
• Initial phase: 15 mg 2× daily for 21 days
• Maintenance therapy: thereafter 20 mg 1× daily
• Dabigatran, Edoxaban → start only after ≥ 5 days of parenteral anticoagulation (e.g. Heparin, LMWH, Fondaparinux)
• Direct oral anticoagulants (DOACs) should be avoided in patients with renal insufficiency as well as in pregnant or breastfeeding women.
Heparin
unfractionated heparin
Initial dose:
80 IU/kg bolus (88 kg) → 7.040 IU → 7.000 IU IV (rounded to the nearest 500)
Then 18 IU/kg/h → 1.584 IU/h → 1.600 IU/h (rounded to the nearest 100)
Adjustment according to aPTT:
< 35 s → additional 80 IU/kg bolus, then +4 IU/kg/h
35–45 s → additional 40 IU/kg bolus, then +2 IU/kg/h
46–70 s → no dose change
> 71 s → reduce dose
Enoxaparin (low-molecular-weight heparin, LMWH):
1 mg/kg BW s.c. every 12 hours (standard for DVT/PE)
1.5 mg/kg BW s.c. once daily (alternative, less commonly used)
The aPTT reflects changes in the intrinsic pathway of the coagulation cascade and is used to monitor heparin therapy.
In DVT patients receiving heparin, the aPTT should be checked at 6, (12) and 24 hours.
Heparin → Antidote: Protamine sulfate
|
Heparin-associated thrombocytopenia (HAT) vs. Heparin-induced thrombocytopenia (HIT) |
||
|
Characteristic |
HAT |
HIT |
|
Cause |
direct effect of heparin on platelet function |
immune-mediated reaction (antibodies against PF4-heparin complex) |
|
Onset |
immediate (within 1–2 days after therapy initiation) |
usually 5–14 days after onset, rarely ‘rapid-onset HIT’ <24 h with prior exposure |
|
Platelet count |
slight decrease, usually > 100,000/mm³ |
Decrease of > 50% of baseline, often < 100,000/mm³ |
|
Severity |
mild, self-limiting |
severe, progressive |
|
Clinical relevance |
usually without complications |
high risk of venous and arterial thromboses |
|
Therapy |
usually none required, heparin can be continued |
immediate heparin cessation, switch to alternative anticoagulation (e.g., argatroban, danaparoid, DOACs) |
Vitamin K antagonists
Parenteral anticoagulation therapy is initiated with a fast-acting agent such as unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux, which is administered for at least 5 days and overlapped with warfarin/phenprocoumon.
• Warfarin (Coumadin®) → usual start 5 mg/day p.o. (US standard)
• Phenprocoumon (Marcumar®, Falithrom®) → usually 1–3 mg/day
• INR target range (for DVT/PE, atrial fibrillation): 2.0 – 3.0
• For mechanical heart valves: INR 2.5 – 3.5
The INR reflects changes in the extrinsic system of the coagulation cascade and is used to monitor oral anticoagulation with vitamin K antagonists (e.g., warfarin, phenprocoumon).
Phenprocoumon is more potent and has an almost fourfold longer half-life than warfarin, which is why a lower drug dose is required!
• Vitamin K antagonists: cross the placenta
• Gestational weeks 6–12: risk of embryopathy
• Nasal hypoplasia
• Epiphyseal calcification disorder (stippling)
• Later pregnancy: risk of fetal bleeding
Vitamin K antagonists → Antidote: vitamin K
Complications
Possible late complications of a VTE include post-thrombotic syndrome, recurrent thromboembolic events, and chronic thromboembolic pulmonary hypertension.
|
Clinical decision score to assess the probability of a DVT |
||
|
Clinical feature |
Points |
|
|
Active cancer (treatment within the last 6 months or palliative) |
1 |
|
|
Paralysis, paresis, or recent immobilization of the leg due to a cast |
1 |
|
|
Prolonged bed rest > 3 days or major surgery within the last 3 months with anesthesia |
1 |
|
|
Localized tenderness along the deep veins of the leg |
1 |
|
|
Entire leg swollen |
1 |
|
|
Calf swelling > 3 cm compared with the asymptomatic side (measured 10 cm below the tibial tuberosity) |
1 |
|
|
Pitting edema confined to the symptomatic leg |
1 |
|
|
Collateral superficial veins (non-varicose) |
1 |
|
|
Previously documented deep vein thrombosis |
1 |
|
|
Alternative diagnosis at least as likely or more likely than DVT |
–2 |
|
|
Interpretation Score ≤ 0 → low probability Score 1–2 → moderate probability Score ≥ 3 → high probability |
||
|
Prediction rule for the probability of pulmonary embolism (PE) — Points |
Points |
|
Previous venous thromboembolism (VTE) |
1,5 |
|
Cancer |
1 |
|
Recent surgery or immobilization |
1,5 |
|
Hemoptysis |
1 |
|
Heart rate > 100/min |
1,5 |
|
Clinical signs of a DVT |
3 |
|
Alternative diagnosis less likely than PE |
3 |
|
< 2 points → low probability 2–6 points → intermediate probability > 6 points → high probability |
|
Up to half of patients with a first episode of VTE have no identifiable risk factors; in these cases it is referred to as unprovoked or idiopathic VTE.
Risk factors for thrombosis
1. Hereditary risk factors
• Antithrombin deficiency, protein C deficiency, protein S deficiency, factor V Leiden mutation
2. Acquired risk factors
• Older age, previous VTE, malignancies, obesity
3. Triggering factors (triggers)
• Surgery, immobilization, pregnancy, estrogen
Extra
Names:
Gerta Altmann, Anna Fischer
Family history:
She has an eight-year-old child who uses a wheelchair. The child wanted a pet, preferably a dog, but the family could not keep a dog. Instead they got a guinea pig, which transmitted a fungal infection of the scalp.
Father: died of myocardial infarction
Medications:
Dolculax
Herbal remedy for menopausal symptoms
Questions
1. We currently have no available beds in the hospital — how would you proceed?
In this case I would assess whether inpatient admission is absolutely necessary. If so, I would transfer the patient to a suitable neighboring hospital. However, we should first confirm that a bed is available there.
2. How would you treat varicose veins?
Baseline therapy consists of compression therapy, exercise and weight reduction. For symptoms or complications, sclerotherapy, endovenous procedures, or surgical measures such as vein stripping may be considered.
3. What if the pain were accompanied by pallor?
Then one would have to consider an acute arterial circulatory disorder. In that case, an immediate vascular surgical consultation, vascular diagnostics (e.g., duplex sonography, angiography) and prompt therapy with anticoagulation or revascularization would be required.
4. What must be considered before administering contrast medium (CM)?
• Renal function
• Allergies
• Thyroid function
• Medication intake – e.g., metformin
• Hydration
5. Which instruments are generally needed for the clinical examination when suspecting an ulcus cruris or a deep vein thrombosis (DVT)?
• Stethoscope – to assess cardiovascular status.
• Measuring tape – to compare limb circumference (unilateral swelling in DVT).
• Flashlight or examination lamp – for wound inspection.
• Gloves – for protection during direct inspection or palpation.
• Thermometer – to detect systemic temperature elevation (fever).
• Sterile forceps and swabs – for gentle cleaning and wound assessment in ulcers.
6. How is the circumference of the lower extremities measured?
If deep vein thrombosis (DVT) is suspected, the circumference of the lower leg should be measured with a tape measure 10 cm below the tibial tuberosity.
• The colors indicate the direction of blood flow:
• Red means blood flow toward the probe
• Blue means blood flow away from the probe
The colors have nothing to do with oxygen content.
7. What is hemophilia?
Hemophilia is a congenital coagulation disorder caused by a deficiency of clotting factors (mostly factor VIII in hemophilia A or factor IX in hemophilia B). It leads to an increased tendency to bleed with spontaneous or injury-related bleeding, especially into joints and muscles.
Notes
BMI
Body mass index (BMI)
Definition and calculation: The BMI is a relative measure for assessing body weight in relation to height. It is calculated from body weight in kilograms divided by the square of height in meters (kg/m²).
Sura
Sura (calf)
Anatomical description: The sura denotes the posterior region of the lower leg, colloquially called the calf. It extends from below the knee to the upper ankle joint.
Planta pedis
Planta pedis (sole of the foot)
Anatomical description: The planta pedis denotes the lower, weight-bearing surface of the foot, i.e. the sole.
Hyperthermia
Hyperthermia
Definition: Hyperthermia denotes an elevated temperature; this can be systemic (fever) or localized to an area of the body.
Dyspnea
Dyspnea
Subjectively perceived shortness of breath, ranging from mild air hunger to severe breathlessness. Common causes are pulmonary diseases, cardiac insufficiency and secondary effects in systemic diseases. Important are details on onset, exertional dependence, at-rest occurrence and accompanying symptoms. In the present context it is documented that no dyspnea is present.
Swelling or pressure sensation in the popliteal fossa
Swelling or pressure sensation in the popliteal fossa
A palpable or visible swelling behind the knee may indicate a popliteal cyst (Baker’s cyst), which is favored by joint effusion or knee joint disease. Differential diagnoses include venous thrombosis, soft tissue tumors or bursitis. Accompanying symptoms such as redness, increased warmth or acute worsening of pain can increase urgency.
a well-demarcated, warm erythematous area
A well-demarcated, warm erythematous area
A sharply demarcated, red and warm skin area is typical for erysipelas (superficial bacterial dermal inflammation). Characteristic are rapid spread, clear demarcation from healthy skin and often accompanying fever or systemic symptoms. Deeply spreading cellulitis as well as other inflammatory or vascular skin changes must be differentiated.
Ulcers
Ulcers
Ulcers are locally limited defects of the skin or mucosa with tissue loss, which can result from pressure, impaired perfusion, infection or neuropathic causes. On the foot, ulcers often occur secondarily with malposition, sensory disturbances (paresthesias/hypesthesia) or nail changes and are clinically relevant because of the risk of infection and impaired wound healing.
Malposition
Malalignment
Malposition denotes the abnormal position of a body part or structure. On the foot such malalignment can lead to altered pressure distribution, formation of pressure points and thereby increased risk for skin damage or ulcers. In clinical assessment the exact local position and the effect on load zones is important.
Paresthesias
Paresthesias
Paresthesias are non-painful, abnormal sensations such as tingling, ‘pins and needles’ or prickling that occur without corresponding external stimulus. They often indicate a disturbance of sensory nerves and occur particularly in peripheral neuropathies in the distal extremities.
Hypesthesia
Hypesthesia
Hypesthesia describes a reduced sensory capacity of the skin to touch, temperature or pain. Such sensory deficits can lead to unintended injuries or delayed wound detection and are a typical sign of peripheral nerve damage.
Polyneuropathy
Polyneuropathy
Definition and clinical features: A polyneuropathy is a disease in which many peripheral nerves are affected simultaneously. Typically this presents symmetrically and predominantly in the distal portions of the hands and feet with symptoms such as paresthesias, sensory loss, burning pain or motor weakness.
Causes and diagnostics: Common triggers are chronic metabolic disorders (e.g. diabetes mellitus), long-term alcohol abuse or a deficiency of certain B vitamins (e.g. vitamin B12). Work-up includes clinical examination and, if necessary, electrophysiological tests for confirmation and classification.
Thromboses
Thrombosis – pathogenesis and risk factors
Thrombosis denotes the formation of a blood clot (thrombus) in a vessel that can restrict or block blood flow. Venous thromboses often lead to swelling, pain and redness in the affected area; arterial thromboses cause acute ischemia. Relevant risk factors include prolonged immobility after surgery, long-distance travel, malignancies, cardiac diseases and coagulation disorders.
Coagulopathies
Coagulopathy – disorders of blood coagulation
Coagulopathies include diseases or conditions that alter normal blood coagulation. This can manifest as an increased tendency to bleed or in some cases as increased thrombotic tendency, depending on the underlying cause. Causes are congenital factor defects, liver disease, vitamin K deficiency, medication effects and malignancies. In the history, recording known coagulopathies is important because they influence the risk of bleeding and in part also thrombotic events.
radicular symptomatology
Radicular symptomatology – root irritation and radicular pain
Radicular symptomatology arises from irritation or compression of a spinal nerve root, often due to disc protrusion or foraminal stenosis. Characteristic are sharp or burning pains radiating along a dermatome into the arm or leg. Sensory disturbances, reflex changes or motor weakness can accompany. Clinical and segment-related neurological deficits help distinguish this from purely local back pain symptoms.
Constipation
Constipation – definition and possible complications
Constipation describes persistently difficult or less frequent bowel movements than usual. Typical accompanying symptoms are hard stool, feeling of fullness and abdominal discomfort. Long-standing or pronounced constipation can lead to sequelae such as anal fissures or hemorrhoids. In the history, duration, possible triggering medications and accompanying symptoms should be asked about.
Varices
Varices (varicose veins)
Definition and pathomechanism:
Varicose veins are permanently dilated and often twisted superficial veins, which most commonly occur in the legs. They are usually caused by insufficiency of the venous valves, so that venous blood flows backward and pools in the affected vessels.
Clinical presentation and risk factors:
Symptoms include a sensation of heaviness or tension, exertion-dependent pain, swelling, and conspicuous, visibly tortuous veins. Chronic cases can lead to skin changes and a tendency to ulceration. Predisposing factors include prolonged standing, overweight, hormonal influences, age, pregnancy, and family predisposition.
Therapeutic principles:
Initially conservative measures such as wearing medical compression stockings, regular exercise, elevation of the legs and modification of strenuous activities are considered. For persistent or advanced findings, minimally invasive procedures (e.g. sclerotherapy, endovenous ablation) or surgical interventions are also available.
mmHg
mmHg — millimeters of mercury
seborrheic
Seborrheic eczema
Clinical picture:
Seborrheic eczema is a chronic inflammatory dermatosis that preferentially occurs at sites with a high density of sebaceous glands, such as the scalp, the face and behind the ears.
Clinical features and triggers:
It is usually recognizable by a greasy-appearing scale accompanied by redness and sometimes itching. Contributing factors can be psychological stress, cold weather, increased sweating and colonization with Malassezia yeasts.
Treatment approaches:
Therapy generally includes topically acting antifungal preparations for the scalp and skin and, if necessary, short-term use of mild topical corticosteroids; additionally, skin care adapted to the skin type is recommended.
Tendovaginitis
Tendovaginitis (tenosynovitis)
Definition and cause:
In a tenosynovitis the tendon sheath that surrounds a tendon and facilitates its gliding movements becomes inflamed. It often arises from repetitive strain or monotonous movement patterns.
Symptoms:
Typical complaints are localized pain, swelling, redness and a rubbing or creaking sensation with movement; the function of the affected extremity can be restricted.
Treatment:
Measures initially include rest and modification of load, physical therapy, possibly anti-inflammatory medications and, if needed, splints for immobilization; invasive treatments are considered in selected cases.
Midfoot
Midfoot (metatarsus)
Structure and function: The midfoot consists of five metatarsal bones (ossa metatarsalia I–V) and together with the adjacent foot bones forms the longitudinal and transverse arches of the foot. It transmits loads during standing and during the roll-off phase when walking or running.
Extrauterine pregnancy
Ectopic pregnancy (EP)
Definition and location: An ectopic pregnancy occurs when the pregnancy implants outside the uterine cavity. The most common implantation is in the fallopian tubes; less commonly ovarian, abdominal or cervical locations occur.
Clinical significance and complications: An EP can lead to tubal rupture with intraabdominal bleeding and, in severe cases, cause hemorrhagic shock. An EP can also have long-term effects on fertility.
Treatment principles: Therapy depends on the clinical condition of the patient and the findings. Options include conservative medical treatment (e.g. systemic therapy in suitable cases) as well as surgical procedures such as tubal-sparing operations or removal of affected structures. The choice of procedure depends on stability, location and the desire for future fertility.
Votum plus 20
Votum plus 20
Active ingredient combination and group: Votum plus is a combination preparation of an angiotensin II receptor blocker (olmesartan medoxomil) and a thiazide diuretic (hydrochlorothiazide).
Mode of action and indication: The active ingredients complement each other in their blood pressure–lowering effect: the angiotensin II receptor blocker inhibits vasoconstrictive and volume-mediated effects of the renin‑angiotensin system, the diuretic reduces intravascular volume. The preparation is used for the treatment of arterial hypertension.
Important risks and monitoring: Side effects may include dizziness, headache and disturbances of electrolyte balance (e.g. electrolyte changes induced by the diuretic). At initiation or change, blood pressure, electrolytes and kidney function should be monitored. Products of this class are contraindicated in pregnancy.
Decoderm
Decoderm
Drug class and use: Decoderm is a topically applied glucocorticoid that exerts anti-inflammatory and antipruritic effects. It is used for short-term treatment of inflammatory skin diseases, for example in atopic dermatitis, allergic or irritant dermatitis.
Usage instructions and precautions: Decoderm is intended for local application; extensive, long-term use or occlusion with dressings can increase systemic absorption. With prolonged use local side effects such as skin atrophy, striae or telangiectasias may occur. Special caution is advised in the presence of signs of skin infections, certain inflammatory dermatoses such as rosacea or perioral dermatitis, and in children.
Ibuprofen
Group: Nonsteroidal anti-inflammatory drug (NSAID).
Mechanism of action: Inhibits cyclooxygenase enzymes, thereby reducing the formation of prostaglandin-mediated inflammatory and pain mediators.
Effect: Has analgesic, antipyretic and anti-inflammatory effects.
Important risks and notes: Common side effects affect the gastrointestinal tract (e.g. dyspepsia, ulcers, gastrointestinal bleeding). Allergic reactions can occur; in patients with preexisting asthma susceptibility there is an increased risk of deterioration. Long-term or high-dose use can affect kidney function and cardiovascular risk. To reduce gastrointestinal complaints, taking with food may be considered; individual contraindications should be checked before use.
Movicol
Group: Osmotic laxative (polyethylene glycol/macrogol).
Mechanism of action: Binds water in the intestinal lumen and thereby increases stool volume and stool consistency through osmotic action.
Use: Used for the symptomatic treatment of constipation and to facilitate bowel movements; use only on medical or therapeutic indication.
Important risks and notes: May cause flatulence, abdominal cramps or diarrhea. Contraindicated if mechanical bowel obstruction or severe intestinal motility disorder is suspected; in pronounced electrolyte disturbances or severe comorbidity, medical evaluation is required.
Pack years
Definition: Pack years are a unit of cumulative tobacco exposure. The usual calculation formula is: (number of cigarettes smoked per day ÷ 20) × number of smoking years.
Calculation for the described patient: With about 20 cigarettes per day for 30 years the result is (20 ÷ 20) × 30 = 30 pack years.
Significance: Pack years are used to estimate the smoking-related risk for diseases such as COPD or cardiovascular disease and are relevant for preventive and diagnostic assessment.
Pediculosis capitis
Definition: Pediculosis capitis refers to infestation of the scalp by head lice (Pediculus humanus capitis).
Transmission: Transmission occurs mainly by direct head-to-head contact; less often via shared hair utensils, hats or towels.
Clinical presentation and consequences: Typical are intense itching of the scalp and finding of lice eggs (nits) on the hair; if untreated, scratching can lead to secondary bacterial infections. When infestation is present, treatment of close contacts and household hygiene measures should also be considered.
Superficial thrombophlebitis
Definition
Superficial thrombophlebitis is an inflammatory change of superficial veins that is often associated with local clot formation.
Clinical features
Typical findings are local pain, a palpable cord-like induration along the affected vein as well as redness and warmth of the skin over the vein. Occasionally swelling and tenderness on pressure occur.
Significance
It is usually a limited superficial condition; however, evaluation is required if symptoms spread or there are indications of involvement of deeper vessels.
Erysipelas
Short definition
An erysipelas is an acute bacterial inflammation of the skin and the superficial lymphatic vessels.
Pathogens and development
Mainly beta-hemolytic streptococci of group A, such as Streptococcus pyogenes, are named as the cause. The bacteria usually enter the tissue and lymphatic vessels through small skin injuries.
Clinical picture
Characteristic is a usually sharply demarcated, intensely reddened skin area with swelling, increased warmth and pain. Systemic accompanying symptoms such as fever, chills and lymph node swelling often occur.
Treatment aspects
Therapy generally consists of targeted antibiotic treatment; supportive measures such as cooling, elevation of the affected extremity and analgesics can provide relief.
Post-thrombotic syndrome
Definition
Post-thrombotic syndrome is a chronic consequence after a deep vein thrombosis, caused by permanent damage to the venous valves and disturbed venous return.
Clinical signs
Affected individuals complain of persistent swelling, pain or a feeling of heaviness in the affected extremity. Over time skin changes can develop and in severe cases open lower leg ulcers (venous leg ulcer) may occur.
Pathophysiological classification
The complaints are based on a combination of venous hypertension and reduced valve function following thrombotic damage.
Blood pressure
Definition of term
Blood pressure denotes the pressure of the circulating blood in the arterial vessels.
Device components for measurement
For manual blood pressure measurement, an inflatable cuff, a bulb for inflation and a manometer for pressure reading, as well as a stethoscope for auscultation, are usually used. Alternatively, automated devices are employed.
Respiratory rate
Respiratory rate
Description: Number of breaths per minute, a central vital parameter.
Classification: In adults a normal rate is approximately between 12 and 20 breaths per minute. An accelerated respiration is called tachypnea (> 20/min), a decreased rate is called bradypnea (< 12/min).
Oxygen saturation
Oxygen saturation (SpO2)
Measurement principle: Peripheral oxygen saturation is measured non-invasively using a pulse oximeter, typically on the finger or earlobe. The device estimates the percentage of oxygen-carrying hemoglobin.
Interpretation and limitations: The measurement provides a quick orientation about oxygenation but depends on perfusion, movement, nail polish and interferences (e.g., carbon monoxide exposure can falsify values). Results must always be assessed together with the clinical picture.
Temperature
Temperature
Measurement sites: Body temperature can be measured at various sites, including rectal, oral and axillary. The choice of measurement site influences the measured value.
CRP
CRP (C-reactive protein)
Function: CRP is an acute-phase protein synthesized in the liver whose concentration increases in inflammatory processes.
Clinical use: Measuring CRP serves as a nonspecific marker of inflammation to support diagnostics and monitoring. Elevated values indicate an inflammatory response but do not specify the cause.
ESR
ESR — erythrocyte sedimentation rate
Definition and measurement principle: The ESR indicates how far red blood cells settle in an anticoagulated blood tube within one hour. The result is given in millimeters per hour.
Physiological basis: The settling of erythrocytes is mainly influenced by changes in plasma proteins (e.g., fibrinogen, immunoglobulins); increased concentrations lead to faster settling.
Clinical significance: The ESR is a nonspecific laboratory parameter for inflammatory or proinflammatory conditions and can be used for monitoring. It does not provide a causal diagnosis and should be interpreted together with other inflammatory markers and clinical assessment.
D-dimers
D-Dimers
Definition: D-dimers are degradation products of cross-linked fibrin that are formed when fibrin is cleaved by the fibrinolytic system (plasmin).
Meaning and use: Elevated D-dimer concentrations indicate activation of coagulation and fibrinolysis. Measurements are often used to assess thrombotic activity; due to high sensitivity and limited specificity they are mainly used to exclude deep vein thrombosis or pulmonary embolism when pretest probability is low to moderate.
Influencing factors: Many non‑thrombotic conditions (e.g. inflammation, recent surgery, malignancies, pregnancy, age) can raise D‑dimer levels, therefore interpretation is context-dependent.
PatientSalutation: Mr./Ms. Senior physician ……….., I would like to present the patient Mrs Elisabeth Altmann to you. |
Date12/09/2025 |
| Age 57 years | Weight 88 kg | Height 166 cm |
Allergies (keywords)
Amoxicillin → urticaria
Lactose intolerance → abdominal complaints (diarrhea, pain)
Substances / drugs (keywords)
Nicotine: 20 cigarettes/day for 30 years (≈20 pack‑years)
Alcohol: occasional wine/beer
Drugs: denied
Social history (keywords)
Occupation: employee in a tax office
Marital status: in a second marriage for 15 years
lives with a 9‑year‑old foster son (pediculosis capitis 2 weeks ago, treated with Nyda® and lice comb)
Family history (keywords)
Father: mesenteric circulatory disorder, died at 75 years.
Mother: 70 years, nursing home; varicose veins, coxarthrosis with hip TEP and re‑TEP after infection, known coagulation disorder
Medications (keywords)
Votum plus® 20/12,5 mg 1-0-0
Decoderm® cream as needed
Femoston for 6 months 1-0-0
Ibuprofen 400 mg tablets as needed
Movicol® as needed
History (full sentences)
The 57‑year‑old patient presented to our clinic after referral by her general practitioner because of acute, progressive, pulling pain of the left lower leg that had existed for two days.
The pain radiates into the calf and as far as the sole of the foot. At rest the pain intensity is about 5/10, with exertion up to 7/10.
She stated that she can hardly bear weight on the leg, neither when walking nor when getting up; elevation relieves the complaints.
Clinically there is shiny skin with a reddish‑bluish discoloration, hyperthermia and a difference in circumference.
For one year there have additionally been trophic changes (eczema) on the left.
Dyspnea and thoracic pain were denied.
Vegetative history is unremarkable except for constipation.
The following are relevant Pre-existing conditions: varicosis for 20 years, arterial hypertension for 12 years (well controlled), seborrheic eczema, tendovaginitis of the left wrist, fracture and ligament rupture of the left metatarsus after bicycle fall 12 years ago.
Previous operations: laparotomy with hysterectomy and right oophorectomy for ectopic pregnancy 20 years ago.
Gynecology: menopause for 9 years; OCP (Jaz®) for 6 months due to climacteric symptoms.
Suspected diagnosis – differential diagnosis (full sentences)
Based on the history and clinical findings, much speaks for a left deep vein thrombosis (DVT).
Risk factors include obesity, nicotine abuse, varicosis and the intake of oral contraceptives.
Differentially, intermittent claudication with exertion‑dependent pain as well as a superficial thrombophlebitis with local pain, palpable venous cord and skin redness are conceivable.
Further approach – therapy (full sentences)
A compression sonography (duplex sonography) of the deep leg veins should be performed.
Additionally, determination of D‑dimers, a coagulation panel and further laboratory chemical parameters is recommended.
If the diagnosis is confirmed, anticoagulation will be initiated.
Concomitantly, adequate pain therapy and elevation of the leg are indicated.
Furthermore, counseling on smoking cessation and weight reduction is recommended.
Signature
First Name Last Name
Yours sincerely
1. Age
2. Main complaint
1. usually over 50 years
(Up to half of patients: unprovoked or idiopathic VTE)
2. Acute onset and progressive pain in the left lower leg ± radiation into the calf and foot.
3. Accompanying symptoms
3.
Pain-related restriction of movement, the affected leg is barely weight-bearing.
Shiny skin with reddish-blue discoloration
Local hyperthermia
Soft, pitting edema
Improvement of symptoms with elevation of the leg.
4. Suspicion of pulmonary embolism
4. Dyspnea, tachypnea, tachycardia, chest pain, anxiety, hemoptysis, hypotension, hypoxemia and reduced cardiac output, central and peripheral cyanosis as well as gallop rhythm
5. Risk factors
Hereditary risk factors:
• Antithrombin deficiency, protein C deficiency, protein S deficiency, factor V Leiden mutation
Acquired risk factors:
• Advanced age, previous VTE, malignancies, obesity, smoking, varicose veins
6. Triggering factors
(Triggers)
Surgery, immobilization (> 3 days), pregnancy, estrogen, recent travel (within 2 weeks, duration ≥ 4 hours) → activation of endothelial cells, stasis (slowing of blood flow), hypercoagulability (increased tendency to clot)
Components of Virchow’s triad
7. Physical Examination
7. Vital signs
Inspection/palpation: swelling in the popliteal fossa, erythema, cyanosis, varicosities, pitting edema
Peripheral pulses, tenderness on pressure along the course of the veins
Comparison of the limbs (circumference, skin temperature, skin color)
8. Measurement of leg circumference
Comparison of both lower legs
Measurement point: 10 cm below the tibial tuberosity
Performed with measuring tape
9. Special tests
Homans’ sign: positive if passive dorsiflexion of the foot with the knee extended produces calf pain.
Payr’s sign: positive if pressure with the fingers on the medial sole of the foot elicits tenderness.
Meyer’s sign: positive if pressure along the great saphenous vein on the inside of the lower leg provokes pain.
8. Laboratory
Blood count, CRP, ESR, D-dimers, INR, aPTT, fibrinogen, electrolytes, creatinine, urea, GFR
Positive D-dimer (high sensitivity) or high clinical probability → confirmation by venous compression sonography (for DVT) or CTPA (for suspected pulmonary embolism)
9. Further management
Electrocardiogram (ECG): sinus tachycardia, possibly typical S1Q3T3 pattern
Compression sonography: absence or incomplete compressibility of the vein
Color duplex sonography: depiction of stenoses, blood flow direction and velocity
CT pulmonary angiography (CTPA): Detection or exclusion of a pulmonary embolism
10. Differential diagnosis
Intermittent claudication: chronic, exertional pain with improvement at rest.
Superficial thrombophlebitis: palpable, painful venous cord, redness, increased warmth
Erysipelas / Cellulitis: redness, swelling, fever
Ruptured Baker’s cyst: swelling in the popliteal fossa
Muscle strain/ trauma
11. Treatment
Reduction or elimination of risk factors
Outpatient therapy: possible for most patients, especially low-risk patients
Anticoagulation (especially direct oral anticoagulants): cornerstone of therapy, duration at least 3 months
Compression stockings: to reduce edema and to prevent post-thrombotic syndrome
Rivaroxaban dosing:
Initial phase: 15 mg twice daily for 21 days
Maintenance therapy: subsequently 20 mg once daily
12. Now imagine: How would you typically present a DVT?
The patient presented with two days of acute onset and progressive pulling pain in the left lower leg.
The pain radiates into the calf and down to the plantar aspect of the foot. The patient can barely bear weight on the leg, neither when walking nor when getting up. Elevation relieves the symptoms.
Clinically, there is shiny skin with a reddish-blue discoloration, hyperthermia, and a difference in circumference.
General term:
1. the calf
2. the sole of the foot
3. the overheating
4. the contraceptive pill
5. the shortness of breath
6. the chest pain
7. the ulcer
8. the malalignment
Fachbegriff:
1. the Sura
2. the Planta pedis
3. the Hyperthermia
4. the contraceptive (oral)
5. the Dyspnea
6. the thoracic pain
7. the Ulcus (Pl. Ulzera)
8. the Malposition
Allgemeinbegriff:
9. the tingling
10. the sensory disorder
11. the blood clot
12. the coagulation disorder
13. the nerve root irritation
14. the varicose veins
15. the blood thinning
Fachbegriff:
9. the Paresthesia
10. the Hypesthesia
11. the Thrombosis
12. the Coagulopathy
13. the radicular symptomatology
14. the Varicosis
15. the Anticoagulation
Komplikationen:
fachleiterinfo@gmail.com
instagram.com/fachleiterinfo
The post-thrombotic syndrome
Cause: destruction of venous valves → chronic venous insufficiency → impaired venous return
Symptoms: chronic leg pain. Swelling (edema), skin changes (hyperpigmentation, eczema, atrophie blanche), Ulcera cruris (open legs)
recurrent thromboembolic events and chronic thromboembolic pulmonary hypertension
To run an AI simulation, download the PDF with the prompt, then upload it to an AI application such as ChatGPT.
Page 1 · 1–20 / 88
DOCTOR: Hello,
My name is Doctor Neumann.
I am working today as a junior doctor on the ward.
I would like to conduct a history-taking conversation with you.
If you do not understand something correctly or have questions, please let me know.
First I need some personal information, then we can continue.
What is your name?
My name is Elisabeth Altmann.
DOCTOR: Could you please spell your first and last name slowly?
Of course,
my first name: E, L, I, S, A, B, E, T, H
And my last name: A, L, T, M, A, N, N
DOCTOR: Now I would like to know: Are the pains still bearable for you?
The pains are quite severe, but I can hold out about 20 minutes until we finish the history-taking.
If I could put my leg on a chair, that would be great.
DOCTOR: Sure, I will arrange that for you right away.
How old are you, Ms. Altmann?
I am fifty-seven years old.
DOCTOR: When exactly were you born?
My birthday is March eleventh, 1968.
DOCTOR: How tall are you?
I am one meter sixty-six tall.
DOCTOR: How much do you weigh?
I weigh approximately eighty-eight kilograms.
DOCTOR: What is the name of your primary care physician?
Her name is Dr. Karla Scholz. I was at her practice about two hours ago.
She saw me in the waiting room, asked about my main complaints and then referred me here.
DOCTOR: All right, how can I help you?
For two days I have had pain in my lower leg.
I was on my way home from the café when the pains suddenly started.
Now they are so severe that I can hardly move or properly bear weight on the leg.
DOCTOR: Where exactly do you have the pain?
Mainly lower left, but it does not stay only there.
The pains also radiate into the calf and down into the sole of the foot.
DOCTOR: Are the pains constant or do they occur in phases?
The pains are present all the time.
DOCTOR: Have the pains changed over time, worsened or stayed the same?
They have worsened.
DOCTOR: How would you describe the pains?
Are they rather dull, pulling, burning or cramping?
It feels like something is constantly pulling on the leg.
DOCTOR: How would you rate the intensity of your pain at rest and with movement on a scale from 1 to 10, where 1 is mild and 10 is unbearable pain?
At rest I would rate the pain at about 5 out of 10, while it increases to around 7 after movement.
DOCTOR: Have you had such pains before?
Have the pains changed in duration, frequency or intensity?
I’ve had a heavy feeling in my legs for a while, probably from the varicose veins – especially when I stand for a long time or travel a lot.
But these pains here are new to me.
DOCTOR: Have you noticed any skin changes like dry or scaly skin, brittle nails, itching, paleness, or hair loss?
Yes, I have actually noticed that.
The skin on the affected leg looks completely different than usual.
It often appears quite shiny and has a reddish-blue color.
Also, for about a year I’ve had a kind of eczema there – the area is dry, constantly itchy and sometimes becomes really scaly.
The dermatologist said that this is caused by the varicose veins.
DOCTOR: Have you noticed any malformations or anything unusual about your feet?
No, I haven’t noticed anything like that with my feet.
DOCTOR: Do you have a sensation of cold or warmth in the affected leg?
Well, I’ve noticed that the affected leg is a bit warmer than normal.
DOCTOR: Have you noticed any swelling?
Since yesterday my leg is also swollen, and the left one looks thicker than the right.
Sometimes I also feel that the skin there is more sensitive.
DOCTOR: Have you noticed primarily swelling and a feeling of pressure behind the knee?
No, I haven’t noticed swelling or a feeling of pressure in that area.
Page 2 · 21–40 / 88
DOCTOR: Have you noticed a clearly demarcated, very hot, red area?
No, I haven’t noticed such a clear, hot, red area.
DOCTOR: Do you have back pain?
No.
DOCTOR: Do you have shortness of breath, cough, palpitations, chest pain or a feeling of tightness in the chest?
No, I have neither shortness of breath nor palpitations, chest pain or a feeling of pressure in the chest.
But you know, doctor – my colleague’s mother suddenly developed shortness of breath back then and died from it.
You just asked about that.
Now I’m afraid… could that happen to me too?
DOCTOR: I understand well that you are worried – especially if you’ve experienced something like that in your circle of acquaintances.
But at the moment I see no indications of such a disease in you.
You have neither shortness of breath nor chest pain, and your circulation is stable.
Those are all very good signs.
Important is: you are here with us, and we will take care of it.
DOCTOR: Where exactly do you have varicose veins?
The varicose veins are mainly visible on the left leg, more precisely on the inner side of the lower leg.
For cosmetic reasons I usually wear long pants.
DOCTOR: Since when have you had the complaints?
Hard to say, but certainly for about 20 years.
DOCTOR: Have you already done anything about it?
Yes, I try to put my legs up more often and wear compression stockings, that helps a bit.
DOCTOR: Why did these develop?
My family doctor explained that they are mainly caused by lack of movement.
DOCTOR: Have the complaints gotten worse?
Yes, I would say the complaints have gotten noticeably worse – maybe by about a third.
Lately I’ve had to sit a lot because since Christmas I’ve had to work significantly more due to staff shortages, often with overtime.
DOCTOR: Have you ever had a blood clot?
No, I haven’t had a blood clot so far.
DOCTOR: Do you have known problems with your blood coagulation?
No, I am not aware of any problems with blood clotting.
DOCTOR: Do you suffer from chronic illnesses such as cancer, heart problems or other inflammatory diseases?
No, I do not suffer from such illnesses.
DOCTOR: Are you currently using hormonal contraceptives or undergoing hormone replacement therapy?
Yes, well for about half a year I haven’t been feeling so well.
I’ve been having hot flashes more often, I’m more easily irritated and my mood fluctuates quite a bit.
That’s why I went to my gynecologist.
She then told me that I’m already in menopause.
After that she prescribed hormones for it.
Since then I’ve been taking them regularly, and overall I feel somewhat better.
DOCTOR: Do you take the hormones as tablets or as a patch? What is the exact name of the medication?
As tablets. It’s called Femoston.
I take that every day, and my complaints have been significantly better since then.
DOCTOR: Have you recently had an operation after which you could hardly move or were mostly bedridden?
No, I haven’t had anything like that recently.
But about 20 years ago I had an ectopic pregnancy.
Back then an open operation had to be performed, and they removed my uterus and the right ovary during that.
DOCTOR: Do you have someone with you?
Yes, my husband will come right afterwards.
DOCTOR: Do you have fever, night sweats, chills or episodes of sweating?
None
DOCTOR: How is your appetite?
I actually like to eat everything, except milk.
DOCTOR: And why don’t you drink milk?
After that I always get diarrhea and abdominal pain.
DOCTOR: I understand, that happens to many people.
Has your weight changed recently?
No, my weight has remained about the same.
But I have been thinking for a while about how I could lose a few kilos.
Is there a medication for that?
DOCTOR: That is a good consideration.
However, when it comes to losing weight, nutrition is the main factor.
Regular exercise helps additionally — and incidentally also improves the symptoms from the varicose veins, because circulation gets better and the muscles get stronger.
Medications can at most be a support, but they are not a substitute for a healthy lifestyle.
Also, you always have to reckon with possible side effects.
It would be best if we drew up a plan for diet and exercise together.
Why not, I’m interested.
But I’d like to add something: A few years ago after a bicycle fall I had severe pain in my foot.
At first I went to the hospital, they took an X-ray there — but that showed no findings.
The pain nevertheless did not improve.
After about two weeks I went again and this time they pushed me into such a narrow tube where you have to lie still.
The whole thing lasted at least half an hour, and it was quite loud.
DOCTOR: How long were you in the hospital in total?
Just a few hours, for observation.
Page 3 · 41–60 / 88
DOCTOR: And what was found back then?
What treatments did you receive?
They saw that there actually was a small fracture in the midfoot, together with a ligament tear.
They immobilized the foot, I had to wear a special boot for several weeks and was hardly allowed to put weight on it.
After that I received physiotherapy until I could walk normally again.
Since then, however, I can’t do certain sports anymore.
DOCTOR: I understand that you are limited in some sports due to the injury.
Many people experience this after a fracture or ligament tear in the foot.
What is important is that you stay active nevertheless so that muscles and joints remain fit.
A very good option would be swimming, because the foot is hardly loaded and you still train your whole body.
Yes, that sounds good.
I could well imagine swimming.
DOCTOR: Do you have nausea?
Have you vomited?
Nothing.
DOCTOR: Do you have difficulties with sleep — that is, falling or staying asleep?
Sometimes I have to get up at night, but after five minutes I fall asleep again.
DOCTOR: How often does that happen?
Maybe once or twice a month, especially when I’m overloaded at work.
Then I suddenly wake up because I think I’m oversleeping and will be late for work.
DOCTOR: What have you done about it?
I drink herbal tea in the evenings.
DOCTOR: Do you have difficulties with bowel movements or urination?
For 10 years I’ve had constipation and occasionally take Movicol.
DOCTOR: I understand. You know, a diet high in fiber and regular exercise often help very well against constipation.
It is also important to drink enough — about eight to ten glasses of water a day can already make a big difference.
Do you actually go to the toilet less often, do you have to strain strongly or is the stool painful?
Bowel movements take a very long time.
DOCTOR: Have you noticed any pain, bleeding or itching in the anal area?
No, not so far.
DOCTOR: How do you deal with stress?
I try to cope with stress by taking a trip or a vacation.
DOCTOR: Do you suffer from chronic diseases such as high blood pressure, diabetes or elevated blood lipids?
I’ve had high blood pressure for 12 years.
DOCTOR: How was the diagnosis made?
Quite by chance actually.
I was in the hospital back then because of the foot injury, and they measured my blood pressure over 24 hours.
It turned out that the values were around 150 over 90.
DOCTOR: Do you measure your blood pressure at home?
How high are the values?
Yes, I measure my blood pressure at home.
The values are thirteen over eight.
DOCTOR: Are there complications such as kidney problems, visual disturbances or cardiovascular diseases?
No, everything is fine there.
DOCTOR: Have you ever been hospitalized because of too high or too low blood pressure values?
No, fortunately not so far.
DOCTOR: When did you last visit an ophthalmologist?
The last time was two years ago.
There were no notable findings then.
DOCTOR: What medications do you take for it?
I take Votum Plus, 20/12.5 milligrams, once daily in the morning.
DOCTOR: Have you had any unpleasant or serious side effects so far?
With the intake of Movicol, flatulence can occasionally occur.
In addition, I constantly have greasy, yellowish or white flakes on the eyebrows and behind the ears.
The skin underneath is often reddened and looks inflamed.
DOCTOR: Are other areas like hands or hair affected as well?
No, it only affects the eyebrows and the area behind the ears.
DOCTOR: What known triggers do you have?
Especially when I’m very stressed or when the weather is very cold, it gets worse.
Also when I sweat heavily, I notice that the flakes become more noticeable.
DOCTOR: How often does it worsen?
I would say, about every two months.
Then it becomes noticeably worse for a few days before settling down again.
Page 4 · 61–80 / 88
DOCTOR: Do you also suffer from asthma or hay fever?
I don’t have those.
DOCTOR: What treatments have already been carried out?
So far treatment with Decoderm cream has been used, which must be applied twice daily.
I’ve had tenosynovitis for eight years, affecting my left wrist.
DOCTOR: How did that come about?
From overuse while working at the computer.
DOCTOR: How does the inflammation present?
Occasionally I get pain, it swells and I can hardly move the hand.
In such phases I take an ibuprofen tablet 400 and also wear a splint to immobilize the wrist.
DOCTOR: Do you take any other medications?
No, nothing else.
DOCTOR: Do you have a prescription for your medications?
Yes, I do.
DOCTOR: Are you in menopause?
Since when?
Well, for 9 years.
DOCTOR: Have you ever been pregnant?
Actually not.
After the removal I could no longer become pregnant.
DOCTOR: I understand, that must not have been easy for you.
Do you remember in which week of pregnancy that was roughly?
Yes, that was still very early back then, so in an early week.
DOCTOR: Did everything proceed without complications, or were there problems such as heavier bleeding?
No, actually not.
There were no major problems.
DOCTOR: When did you last consult a gynecologist?
I last saw a gynecologist two years ago, who found no abnormal findings.
DOCTOR: Are you fully vaccinated, that is, have you had all vaccinations since your childhood?
Doctor, honestly, what can I say – I can’t really remember anymore.
DOCTOR: I would say you are right – we can check that later via the vaccination record.
At the moment it’s not necessarily urgent.
Do you have known allergies, for example to foods, medications, animals or other substances?
Yes, I have an allergy to amoxicillin.
After the operation on the uterus I received it to prevent infection.
Shortly afterwards I developed an itchy rash over my whole body.
The spots kept changing and migrated from one place to another.
DOCTOR: And which antibiotic were you given afterwards?
After that I was prescribed azithromycin.
I tolerated that well too.
DOCTOR: Do you smoke?
How many cigarettes do you smoke daily and since when?
I’ve smoked 20 cigarettes daily for 30 years.
I would like to know how I can quit smoking or at least reduce it.
DOCTOR: That is a very good decision.
We should talk about it in more detail calmly.
There are various ways to quit smoking or at least smoke less – for example with pharmacological support, nicotine replacement products such as patches or gums, or with behavioral therapy programs.
DOCTOR: Do you cough particularly at night?
No, I only rarely cough at night.
DOCTOR: Do you drink alcohol?
What type?
How much?
Occasionally I drink wine or beer.
DOCTOR: May I ask whether you have ever used drugs?
Never
DOCTOR: What is your occupation?
Do you work self-employed or are you employed?
I work in a tax office.
DOCTOR: What is your marital status?
I have been married for the second time for 15 years.
Page 5 · 81–88 / 88
DOCTOR: Who do you live with?
I live with my family in an apartment.
DOCTOR: On which floor do you live?
I live on the third floor, but fortunately there is an elevator.
DOCTOR: Do you have children?
Yes, we have a foster son, he is nine years old.
Two weeks ago he unfortunately had head lice.
Therefore we got a remedy against it at the pharmacy, Nyda, and also used the lice comb.
Fortunately everything is fine again now.
DOCTOR: Are there significant illnesses in your family, for example in your parents, siblings or other close relatives?
My father often had abdominal pain back then, especially after meals.
He therefore visited the doctor more often and was prescribed pantoprazole, but that did not help.
The colonoscopy was unremarkable.
Later, at the age of 75, he became significantly worse, and an intestinal circulatory disorder was diagnosed.
Unfortunately, he passed away from it a few days later.
My mother is 80 years old and lives in a nursing home.
She has varicose veins and had to receive a new hip joint because of joint wear.
After the operation there was unfortunately an infection, so the joint had to be removed and replaced with a new one.
She also has some kind of coagulation disorder.
DOCTOR: I am sorry to hear that.
That must have been a difficult time for you.
Do you know exactly what this coagulation disorder is called?
Unfortunately not exactly.
But I know that she gets bruises more often, sometimes even without having bumped herself.
In the past she also had heavier bleedings more often, for example after minor injuries.
She receives medication for that so that the blood clots better.
DOCTOR: Have you traveled recently?
No, I have not taken any trips recently.
DOCTOR: Do you have pets?
I do not have any pets.
DOCTOR: We are finished with the medical history.
Do you have any further questions?
Can I go home today?
I cannot say that for sure at the moment.
We can only determine the correct treatment once all further examinations are completed.
But it is best to expect that an inpatient admission may be necessary.
Please do not worry – our team cares for and supports you in every situation.