SUBJECTIVE DATA (S):
IDENTIFYING DATA:
Initials: P.B.
Age: 76 years
Race: Caucasian
Gender: Male
CHIEF COMPLAINT (CC): Patient c/o “leg pain and swelling x2 days”.
HISTORY OF PRESENT ILLNESS (HPI): Patient states he slipped off the step of his camper
and fell 2 days ago and hurt his right lower extremity. His leg started to swell and became more
painful 1 day after the occurrence. Patient states that today his right lower extremity is swelling
even more and feels very tight. Patient states he believes he hit his leg on one of the steps
when he fell.
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location: right lower extremity
quality: patient describes a feeling of tightness
severity: patient rates pain a “5” on a scale from 1-10. He states the pain is now
constant and is continuing to worsen
timing: symptoms started 2 days ago
setting: patient states his symptoms started after he slipped off the step of his
camper 2 days ago
alleviating and aggravating factors: pain in leg is worse when the patient tries to
flex his lower leg and when he walks. He says it feels a little better when he is
resting with his leg elevated.
associated signs and symptoms: swelling, warmth, and redness in right lower
extremity
PAST MEDICAL HISTORY (PMH):
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Allergies: NKDA
Current medications: altace 10 mg capsule, claritin 10 mg tablet
Age/health status: 76 years
Appropriate immunization status: Up to date on all vaccines; He states he had
his tetanus-diptheria booster 6 years ago and has had the herpes zoster vaccine.
Flu and pneumonia vaccines given October 2013. He states he will be getting the
flu vaccine at his primary physician’s office this fall.
Previous screening tests result: Patient states he has a yearly physical each year
and has his cholesterol, PSA level, and other labs checked. All lab work was
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reported normal in May 2014. Colonoscopy was done at age 65 and was
reported normal.
Dates of illnesses during childhood: N/A
Major adult illnesses: Patient states he has a history of HTN and allergic rhinitis
Injuries: N/A
Hospitalizations: Patient states he was in the hospital with pneumonia about 10
years ago. He explains that he receives a pneumonia vaccine every 5 years now.
Surgeries: Patient denies having any surgery
FAMILY HISTORY (FH): Father died at the age of 82 from an AMI. Mother died at the age
of 88 from complications from Type II diabetes. Patient states he is unsure of their complete
medical history. Patient has 1 sister who has HTN as well. He has 2 children who are alive and
healthy at the age of 54 and 49.
SOCIAL HISTORY (SH): He is married and is a retired police officer. He is independent
with his ADLs and lives with his wife. He states he and his wife currently exercise about 3 times
per week which includes going to the mall in the morning for brisk walking for about 1 mile. He
is a former smoker- ½ pack/day but he states he quit about 30 years ago. He does drink alcohol
occasionally if he is at a social event. He drinks caffeine (coffee, tea, or soda) 1-3 times daily. No
illicit drug use.
REVIEW OF SYSTEMS (ROS):
1. Constitutional symptoms- Patient denies fever, fatigue, chills, malaise, night
sweats, unexplained weight loss or weight gain, loss of appetite.
2. Eyes- Patient denies blurred vision, difficulty focusing, ocular pain, diplopia,
scotoma, peripheral visual changes, and dry eyes. Patient states he does wear
corrective lenses and has for the last 20 years. Date of last eye exam was in
2013.
3. Ears, nose, mouth, and throat- Patient denies vertigo, sinus problems,
headaches, epistaxis, dental problems, oral lesions, hearing loss or changes,
nasal congestion, sore throat, hoarseness. Date of last dental visit was about 8
months ago.
4. Cardiovascular- Patient has a history of HTN. He states he was diagnosed several
years ago but it is managed well with altace. Patient states he exercises about 3
times a week for about 30 minutes to an hour. Patient denies any history of
heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose
veins, edema. Date of last EKG and cholesterol level was in May 2014 at his
yearly physical and was reported normal.
5. Respiratory- Patient denies cough, SOB, difficulty breathing, wheezing, pain with
inspiration, chest tightness, history of respiratory infections, exposure to TB,
hemoptysis. Patient states he had a chest x-ray about 10 years ago when he was
hospitalized with pneumonia. He is unsure of when his last TB skin test was
done. Patient states he is a former smoker but quit about 30 years ago.
6. Gastrointestinal- Patient denies dysphagia, reflux, pyrosis, loss of appetite,
bloating, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or
epigastric pain, hematochezia, change in bowel habits, food intolerance,
flatulence, hemorrhoids. Patient states he tries to eat healthy, well-balanced
meals.
7. Genitourinary- Patient denies urgency, frequency, dysuria, suprapubic pain,
nocturia, incontinence, hematuria, history of stones.
8. Musculoskeletal- Patient reports pain and swelling in the RLE. Patient denies
back pain, joint pain, muscle cramps, neck pain or stiffness, changes in ROM. He
states he exercises about 3 times a week. He does wear his seatbelt.
9. Integumentary- Patient reports redness and warmth of RLE. Patient denies
itching, uritcaria, hives, nail deformities, hair loss, moles, open areas, bruising.
Patient denies breast tenderness, masses, skin changes.
10. Neurologic- Patient denies weakness, numbness, headache, tingling, memory
difficulties, involuntary movements or tremors, syncope, stroke, seizures,
paresthesias.
11. Psychiatric- Patient denies nightmares, mood changes, anxiety, depression,
nervousness, insomnia, suicidal thoughts, exposure to violence, or excessive
anger.
12. Endocrine- Patient denies cold or heat intolerance, polydipsia, polyphagia,
polyuria, changes in skin, hair or nail texture, unexplained change in weight,
changes in facial or body hair, changes in hat or glove size, use of hormonal
therapy.
13. Hematologic/lymphatic- Patient denies unusual bleeding or bruising, lymph
node enlargement or tenderness, fatigue, history of anemia, blood transfusions.
Patient is unsure of last HCT result but states all lab work was done at his last
physical in May 2014 and everything was reported to him as “normal”.
14. Allergic/immunologic- Patient reports a history of seasonal allergies. He states
he has always had allergies but it is now managed well with Claritin. Patient
denies exposure to blood or body fluids, use of steroids, or immunosuppression
in self or family. He is unsure of his last Hep B vaccine but knows he is up-to-date
on all vaccines.
OBJECTIVE DATA (O):
1. Constitutional- VS: Temp- 99.1, BP- 133/81, HR- 84, RR- 18, O2 sat- 99%, Height6’4”, Weight- 220 lbs, BMI- 26.78; General Appearance: healthy-appearing, wellnourished, and well-developed. Level of Distress: NAD. Ambulation: ambulating
normally.
2. Eyes- sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally.
Extraocular movements intact.
3. Ear, Nose, ThroatEars: external appearance normal-no lesions, redness, or swelling; on otoscopic
exam tympanic membranes clear. Hearing is intact.
Nose: appearance of nose normal with no mucous, inflammation, or lesions
present. Nares patent. Septum is midline.
Mouth: pink, moist mucous membranes. No missing or decayed teeth.
Throat: no inflammation or lesions present. Tonsils WNL- no erythema, ulcers,
masses, exudate, inflammation.
4. Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
Carotid Arteries: normal pulses bilaterally, no bruits present
Pedal Pulses: 2+ bilaterally
Extremities: +2 edema in RLE; no cyanosis, clubbing, less than 2 second refill
5. Respiratory- Even and unlabored. Clear to auscultation bilaterally with no
wheezes, rales, or rhonchi
6. Gastrointestinal- abdomen soft and nontender to palpation, nondistended. No
rigidity or guarding, no masses present, BS present in all 4 quadrants
7. Genitourinary- No bladder distention, suprapubic pain, or CVA tenderness.
Prostate exam was not performed.
8. Musculoskeletal- RLE +2 pitting edema, + Homan’s sign, redness, warmth, and
tenderness noted. Joint stability normal in all extremities, no tenderness to
palpation in all other extremities
9. Integument/lymphaticInspection: No scaling or breaks on skin, face, neck, or arms.
General palpation: no skin or subcutaneous tissue masses present, no
tenderness, skin turgor normal
Face: no rash, lesion, or discoloration present
Lower Extremities: RLE redness and warmth; no rash, lesion, or LLE discoloration
present
Upper Extremities: no rash, lesion, or discoloration present
10. Neurologic- Grossly oriented x3, communication ability within normal limits,
attention and concentration normal. Sensation intact to light touch, gait within
normal limits
11. Psychiatric- Judgment and insight intact, rate of thoughts normal and logical.
Pleasant, calm, and cooperative. Patient appears to be happy/content.
12. Hematologic/immunologic- Lymph nodes not palpable, no tenderness or masses
present, no bruising
DIAGNOSTIC TESTS:
US DOPPLER VENOUS LOWER EXT - 09/17/14
CPT Code: 93971
Results: There is deep venous thrombosis involving the right superficial
femoral popliteal and posterior tibial veins
ASSESSMENT (A):
Level of visit: new office outpatient visit- 99203
1. Deep Vein Thrombosis
453.40: Deep vein thrombosis, unspecified
Swelling, pain, warmth, and redness of right lower extremity. Positive Homan’s
sign. Doppler venous ultrasound confirmed deep venous thrombosis.
2. 311: Hypertension
Currently controlled. Patient is taking altace 10 mg capsule daily
3. 530.81: Allergic rhinitis
Currently controlled. Patient is taking claritin 10 mg tablet daily
Differential Diagnoses:
1. Muscle strain 848.9
Swelling, pain, warmth, and redness of right lower extremity
Refuting data: Doppler venous ultrasound confirmed deep venous thrombosis.
2. Cellulitis 682.6
Swelling, pain, warmth, and redness of right lower extremity
Refuting data: Doppler venous ultrasound confirmed deep venous thrombosis.
3. Peripheral vascular disease 443.9
Swelling, pain, warmth, and redness of right lower extremity
Refuting data: Doppler venous ultrasound confirmed deep venous thrombosis.
4. Popliteal (Baker’s) cyst
Swelling, pain, warmth, and redness of right lower extremity
Refuting data: Doppler venous ultrasound confirmed deep venous thrombosis.
PLAN (P):
1. Patient sent to emergency department via private vehicle. Report called and
given to Dr. Beasley in ED.
2. Continue taking altace 10 mg PO daily to manage HTN.
Continue follow-up with primary physician every 3 to 6 months. Keep a log of
daily blood pressures to take to all doctor appointments.
3. Continue taking claritin 10 mg PO daily to manage allergic rhinitis. Continue
follow-up with primary physician.
Medication profile: Altace
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Indication: Angiotensin-converting enzyme (ACE) inhibitor, used to treat
hypertension, congestive heart failure (post AMI), AMI/Stroke prevention
in patients age 55 years and older
MOA: ACE inhibitors inhibit the actions of angiotensin converting enzyme
(ACE), thereby lowering the production of angiotensin II and also
decreasing the breakdown of bradykinin. The decrease in angiotensin II
results in relaxation of arteriole smooth muscle leading to a decrease in
total peripheral resistance, reducing blood pressure as the blood is
pumped through widened vessels.
Dose:
 HTN- 2.5 to 20mg/day PO divided q day-bid
Start: 2.5mg PO daily; 1.25mg PO daily if hypovolemia or renal
artery stenosis
 CHF, post MI- 5mg PO bid
Start: 2.5mg PO bid; 1.25mg PO daily if hypovolemia or renal
artery stenosis; increase dose every 3 weeks to target
 Cardiovascular event prevention- 10mg PO daily
Start: 2.5mg PO daily x7 days, then 5mg PO daily x3 weeks, then
10mg PO daily; start 1.25mg PO daily if hypovolemia or renal
artery stenosis; may divide bid if MI or HTN; for patients >55 yo
with CAD, stroke, PVD, or DM history plus 1 other risk factor
Brand name/generic: Altace (ramipril)
Prices for 30 capsules of ramipril 10mg (generic)
-Publix: $67 cash or $6.16 with coupon
-Wal Mart: $9.04 with discount
-Target: $35 cash or$6.16 with coupon
-Walgreens: $63 cash or $12.37 with coupon
Follow up: By the vascular specialist to whom the patient is referred.
Consultation/referral: Patient sent to emergency department for treatment. Report
called to Dr. Beasley. Patient should be referred to a specialist with expertise in vascular
medicine and coagulation disorders.
Patient Education:
-Explain what a DVT is: a blood clot in the deep veins of the leg. The clot can clog the
vessel and keep blood from getting where it needs to go. Blood backs up and causes
swelling and pain.
-Explain potential complications: if not treated, clot can travel to other parts of the body
and clog vessels there. When a clot breaks off and moves through the bloodstream, this
is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other
area, leading to severe damage or even death.
-Emergency signs and symptoms: panting or SOB, sharp chest pain when you breathe in
or strain, coughing or coughing up blood, rapid HR
-Explain why he is being sent to the emergency room: You will need to be evaluated by a
vascular surgeon to decide treatment options since it is a large, obstructive clot. Possible
treatments include anticoagulants- heparin is usually the first drug you will receive.
Coumadin is usually started as well. You will most likely take warfarin for at least 3
months. Some people must take it longer, or even for the rest of their lives, depending
on their risk for another clot. You will be given a pressure stocking to wear on your leg
or legs. A pressure stocking improves blood flow in your legs and reduces your risk for
complications from blood clots. It is important to wear it every day. In rare cases, you
may need surgery if medicines do not work. Surgery may involve: Placing a filter in the
body's largest vein to prevent blood clots from traveling to the lungs or removing a large
blood clot from the vein or injecting clot-busting medicines
-Prevention: To prevent deep vein thrombosis:
Wear the pressure stockings your doctor prescribed.
Moving your legs often during long plane trips, car trips, and other situations in which
you are sitting or lying down for long periods.
Take blood thinning medicines your doctor prescribes.
Do not smoke.