Patient Presentation
Chief Complaint
“I’m having pain in my leg.”
HPI
Rodney Cross is a 48-year-old man who presents to his primary care physician because of
pain in his right leg. He states that he awoke with the pain 3 days ago and that it has been
continuous, although it hurts more when he walks. The pain is located behind his right knee
and extends down into his calf. He rates the pain intensity as 3/10 at this time. The patient
denies CP and SOB. He denies recent travel, immobility, and leg injury. The patient did
start pravastatin 40 mg daily for treatment of dyslipidemia approximately 3 months prior to
this visit. He stopped the pravastatin 3 days ago because he thought it might be causing his
leg pain, but the pain has continued.
PMH
Hypertension
Dyslipidemia
Graves’ disease with thyroid ablation
Gout
Left ankle fracture 9 years ago that required a cast but no surgery
Remote history of depression
PSH
Left herniorrhaphy about 10 years ago. Pilonidal cyst excision in remote past.
FH
Father died at age 81 of liver failure. Mother, one brother, and son all alive and well. No
family history of venous thromboembolism or clotting disorders.
SH
Married, one adult child. Drinks one to two alcoholic beverages daily. Smokes one cigar per
month, no cigarettes. Denies illicit drug use.
Meds
Allopurinol 300 mg po once daily
Hydrochlorothiazide 12.5 mg once daily
Lisinopril 10 mg once daily
Levothyroxine 150 mcg po once daily
Pravastatin 40 mg po once daily (discontinued 3 days ago)
All
NKDA
ROS
Constitutional: No chills, no fatigue.
Eyes: No eye pain or changes in vision.
ENT: No sore throat.
Skin: No pigmentation changes, no nail changes.
Cardiovascular: No CP, palpitations, or syncope.
Respiratory: No cough, SOB, wheezing, or stridor.
GI: No abdominal pain, nausea, diarrhea, or vomiting.
Musculoskeletal: No neck pain, back pain, or injury.
Neurologic: No dizziness, headache, or focal weakness.
Psychiatric/behavioral: Remote history of depression. Not a current problem.
Physical Examination
Gen
Somewhat overweight, Caucasian man who appears comfortable. Cooperative, A & O × 3,
normal affect.
VS
BP 132/76, P 75 regular, R 16, T 98.3°F, O2 sat 97/RA; Wt 194 lb, Ht 6′0″
Skin
Warm, dry, normal color. No rash or induration.
HEENT
Pupils equal and reactive to light. EOM intact. Mucous membranes moist and pink.
Neck
Normal range of motion with no meningeal signs
Lungs/Thorax
Breath sounds normal, no respiratory distress
CV
RRR, no rubs, murmurs, or gallops
Abd
Nontender, no masses, no distension, no peritoneal signs
MS/Ext
Upper extremities: Normal by inspection, no CCE, normal ROM.
Lower extremities: Right calf tight, warm to touch, and tender with 1+ pretibial pitting edema.
LLE without redness, warmth, and swelling. Lower extremity pulses and sensation are
normal bilaterally. Normal ROM.
Neuro
Glasgow coma scale of 15, no focal motor deficits, no focal sensory deficits
Labs
Na 140 mEq/L
K 3.9 mEq/L
Cl 103 mEq/L
CO2 27 mEq/L
BUN 10 mg/dL
SCr 0.84 mg/dL
Glucose 88 mg/dL
Uric acid 5.0 mg/dL
CK 117 IU/L
WBC 5.9 × 103/μL
RBC 4.28 × 106/μL
Hgb 13.5 g/dL
Hct 39.3%
MCV 92.0 fL
MCHC 34.4 g/dL
RDW 14.3%
Platelets 175 × 103/μL
Mean platelet volume 7.2 fL
Granulocytes, electronic 51.0%
Lymphocytes, electronic 38.2%
Monocytes, electronic 8.4%
Eosinophils, electronic 1.9%
Basophils, electronic 0.5%
INR 1.0
Lower extremity venous duplex ultrasonography: “Acute DVT of right distal superficial
femoral, popliteal, and peroneal veins. No compression or flow in these vessels.”
(Note to reader: The “superficial femoral vein” is actually a deep vein, in spite of its name.
Use of the name “femoral vein” is preferred because it is less confusing. However, the name
“superficial femoral vein” is still encountered, as it is in this patient’s venous duplex report.)
Assessment
Acute DVT in right distal femoral, popliteal, and peroneal veins