Ann Luna
January 28, 14
Sonstein/Hill
Date of Encounter: 1/14/2014 (RTC Again on 1/23/2014)
Location of Encounter: UTMB Geriatric Clinic
Identifying Information:
PA; 75 years old; Female; White
Subjective
Chief Complaint:
“My right leg has been bothering me for the past 2 months.”
History of Present Illness:
PA has had gradual onset of right leg pain for the past two months in her calf. Her
pain does not radiate and describes it as a constant burning that is worse with
pressure. An aggravating factor includes applying point pressure to her calf and
weight bearing activities. PA has found minimal relief with acetaminophen, rest, and
sitting. She has not noticed a time of day or pattern associated with her pain but
notices’ swelling is worse at night. PA rates the severity of her pain as a 6 on a 0 to
10 point scale. PA admits to her calf feeling warm and a rash present. PA was
diagnosed with cellulitis in her right calf on 12/23/2013 and was treated with
Levaquin 500 mg tablet daily for 10 days. PA has noticed some improvement, but
her leg continues to hurt. PA denies any fever, itching, night sweats, recent trauma,
or change in weight.
Current Health Status:
Allergies: Versed
Medications: Coreg 25 mg BID, Lexapro 20 mg QD, Hydrochlorothiazide 12.5 mg QD,
losartan 100 mg QD, Lantus 60 units QAM, Aspirin 81 mg QD
Immunization Status: Pneumococcal 1/1/2005, Influenza High Dose 12/9/2013,
Shingles 9/4/2009, Td 12/31/2007
Habits: Former smoker quit 1971, Consumes 1.0 oz. alcohol/week, Denies Drug use,
Consumes 1-2 cups of coffee/day
Health Maintenance: Last physical exam 12/23/2013, Mammogram 1/2012, PAP
2004, Colonoscopy 2010
Self Exams: Performs breast self exams
Nutrition: Poor diet and skips meals when taking insulin
Exercise: Does not exercise
Relevant Past Medical History:
General Health: Poor Health Status
Surgeries: Bilateral hip replacement in 2008 & 2009, 3 Episiotomies 1960-1970
Blood Transfusions: Denies
Hospitalizations: 1960-1970 for childbirth, 2008 & 2009 Hip Replacement
Serious Accidents/Injuries/Fractures: Denies
Major Illnesses: Hypertension, Edema, Gout, Diabetes mellitus type 2, Obesity,
Depression
Limitations of ADL: Not able to walk more than 2 blocks without feeling pain in her
right leg and the pain is constant whether she’s walking or not.
Social History:
Patient lives in a 2-bedroom apartment with her husband, granddaughter, and great
granddaughter. PA is retired from retail. PA worries about money and has few
resources to rely on. She cares for her debilitated husband and has an estranged
relationship with her daughter. She is helping her granddaughter get through
school, and the family is currently sharing one vehicle. PA has no military
background and no religious or cultural considerations that would affect her care.
Patient Explanatory Model:
PA believes that her pain in her right leg is in her bone. She would like to receive
relief from her pain and discomfort. PA would like to find the source of her pain so
she can continue to care for her family.
ROS:
Constitutional: denies chills, fever, and sweats
CV: denies chest pain and denies palpitations
Respiratory: denies chest congestion, denies cough and denies SOB
GI: denies abdominal pain, anorexia, constipation, and diarrhea
GI: denies dysuria
MSK: admits to gait disturbance r/t right calf pain, denies back pain and denies joint
pain
Skin: localized redness in right medial calf
Psych: denies anxiety, depression, and insomnia
Endocrine: does not check BG regularly
Objective
Physical Exam:
BP: 125/79, pulse 102, temp 36.1, O2 92%, Wt 221lb
General: alert, oriented times three, no apparent distress, age appropriate
Skin: rash noted on right calf with no warmth
Lungs: clear bilaterally with good air movement
Heart: regular rate and rhythm
Abdomen: obese, positive bowl sounds in all quadrants
Extremities/Musculoskeletal: no cyanosis, 2+ pitting edema in right lower leg, 1+
pitting edema in left lower leg, pedal pulses not palpable bilaterally, sensation intact
bilaterally with microfilament test
Diagnostic/Lab Data:
Unilateral Venous Duplex Lower Extremity by Vascular Lab
Tibia-Fibula, 2 Views
Assessment
Medical Diagnosis:
Right leg pain d/t edema r/t venous insufficiency
Differential Diagnoses:
Deep Vein Thrombosis
Cellulitis
Fracture of unspecified bone, closed
Plan (1/14/2014):
Therapeutics: Daily use of ted hose and elevate legs above heart 2x/day (Hollier,
2011)
Pharmacotherapeutics: Tylenol 650mg BID as needed for pain (Hollier, 2011)
Diagnostic Tests: Unilateral venous duplex lower extremity-evaluates blood flow in
people with symptoms of leg pain, swelling, or varicose veins (Margolis, 2012) ;
Tibia-Fibula, 2 views
Patient Education & Counseling: Pain most likely associated with stretching of skin
with daily swelling and needs to reduce swelling with daily use of TED hose and
elevating legs above heart; Educated on not taking an NSAID d/t SE of edema
(Maddox, 2012) Maintain a sodium-restricted diet to help limit fluid retention
(Maddox, 2012); Counsel on weight loss
Consults/Referrals: None
Follow-up Care: RTC 2 weeks if symptoms not improving, Will call with results from
Doppler study and X-ray
Rationale and Citations:
Medical Diagnosis:
729.5 Leg Pain, right d/t Edema r/t Venous Insufficiency-Chronic: symptoms of
edema and pain worse in PM, minimal swelling in AM; PA has main symptom of pain
in right calf (Maddox, 2012)
Differential Diagnoses:
453.4 Acute venous embolism and thrombosis of unspecified deep vessels of lower
extremity-symptoms of swelling in one or both legs, Pain/Tenderness with
standing/walking, red/discolored skin/Leg Fatigue (Smith, 2012)
459.81 Venous (peripheral) insufficiency, unspecified-forward flow obstructed d/t
blood clot or backward leakage of blood flow through damaged valves or both; risk
factors of older age, obesity, inactivity, and muscle weakness; symptoms are edema,
skin discoloration, aching/burning/throbbing in legs cramping, and leg weakness
(Cunha, 2013)
682.6 Cellulitis and abscess of leg, except foot-Hx Cellulitis, Diabetic, Chronic leg
swelling, and obesity (Stoppler, 2013)
829.0 Fracture of unspecified bone, closed-Acute-Bone pain
Plan (1/23/2014):
Continue plan from 1/14/2014.
Unilateral Venous Duplex: Negative
Tibia-Fibula: Negative
Medical diagnosis: Right leg pain r/t venous insufficiency
Differential diagnosis: Cellulitis
Started on First generation cephalosporin (MRSA not suspected) after past
treatment with a fluoroquinolone (Levaquin).
Begin Keflex 500 mg tablet; take 1 Tab by mouth 2 times daily for 14 days (Hollier,
2011)
Continue to elevate legs above heart 2x/day, wear ted hose during day, complete
course of antibiotics and RTC in 3 weeks. Call if symptoms worsen or do not
improve.
References:
Cunha, J.P. (2013). Edema. MedicineNet.com. Retrieved from
http://www.medicinenet.com/edema/page3.htm
Hollier, G. & Hensley, R. (2011). Clinical Guidelines in Primary Care: A Reference
and Review Book. Lafayette, LA: Advanced Practice
Education
Associates, Inc.
Maddox, T.M. (2012). Edema Overview. Heart
Failure Health Center. Retrieved from
http://www.webmd.com/heart-disease/heart-failure/edema- overview?
page=2
Margolis, S. (2012). Venous Duplex Ultrasound. Heart and
Circulation Tests.
Retrieved from
http://www.healthcommunities.com/heart-tests/venousduplexultrasound-doppler-studies.shtml
Smith, M.W. (2012). Symptoms and Diagnosis of Deep Vein
Thrombosis (DVT).
Deep Vein Thrombosis Health Center.
Retrieved from
http://www.webmd.com/dvt/deep-vein-thrombosis-dvt-symptomsdiagnosis?page=2
Stoppler, M.C. (2013). Cellulitis.
MedicineNet.com. Retrieved from
http://www.medicinenet.com/cellulitis/article.htm