Identifying Data:

Full Name: MD

Address: Queens, NY

Date of Birth: xx/xx/1951

Date & Time: 10/11/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: redness over left calf x 2 weeks.

History of Present Illness:

70 yo female with PMH of HTN, GERD, varicose vein c/o redness over her left calf x 2 weeks. Reports the area was dark-red initially and it extended from left ankle to mid-calf. She tried compression stockings over the past 2 weeks and states majority of the redness has improved. However, one small area over the mid-calf remains red and tender to touch. She describes the pain as dull, intermittent, non-radiating, at a severity of 4/10, exacerbated by touching. She has tried Tylenol with some symptom relief. Patient reports she spoke with her PCP regarding this complaint, and she was advised to go to ED to r/o clot. Patient went but did not receive any testing/treatment because the wait time was too long.

Denies trauma, fever, chills, chest pain, palpitation, SOB, hemoptysis, pain with ambulation, headache, recent surgery, traveling, and prolonged inactivity.

Past Medical History:

Hypertension

GERD

Varicose vein

Past Surgical History:

Denied

Medication:

Lisinopril 10 mg PO once daily

Omeprazole 40 mg PO once daily

Allergies:

NKDA

Denied food or environmental allergy

Family History:

Denied family history of cardiac disease, cancer, and psychiatric conditions

Social History:

Habits: Denies alcohol, tobacco and illicit drug use.

Travel: Denies recent traveling

Marital History: Married

Home: Patient lives with her husband. Independent in all ADLs and IADLs.

Review of System:

General –Denied recent weight change, fatigue, fever, and night sweats

Skin – Admits to redness over left calf. Denied moles, change of skin texture, itchiness.

Head – Denied headache, light-headedness, recent head trauma.

Eyes – Denied visual changes.

Ears –Denied deafness, or use of hearing aids.

Nose – Denied discharge, obstruction, epistaxis, loss of smell.

Mouth/throat – Denied sore throat, bleeding gum, mouth ulcers, voice change.

Pulmonary system – Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain or palpitation.

Gastrointestinal system – Denied abdominal pain, constipation, diarrhea, and hemorrhoids.

Genitourinary system – Denied urinary frequency, urgency, oliguria and incontinence.

Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.

Musculoskeletal system – Denied joint pain, back pain, muscle pain.

Endocrine system – Denied polydipsia, polyphagia, heat intolerance, goiter, or excessive sweating.

Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 98.3 F, oral

BP: 130/75

Pulse: 56/min

RR: 18, unlabored

O2 saturation: 99% room air

BMI: 29.9

General – AAO X3. Not in acute distress. Able to speak in full sentences. Well-developed and well-groomed.

Skin – 2 x 3 cm of firm, erythematous area over a distended vein on the left mid-calf. Warm and tender to palpation. No open wound. Skin warm and dry, poor turgor, no jaundice.

Hair – Average quantity and distribution.

Nails – No clubbing, capillary refill <2 seconds on fingers and toes.

HEENT – External ear normal. TM is pearly white, intact with light reflex. Normocephalic, atraumatic, external ears normal, no periorbital edema, anicteric, conjunctivae pink, EOMI, oral mucosae moist.

Neck – Supple. No elevated JVD. No lymphadenopathy. No cervical adenopathy noted.

Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs–Clear to auscultation bilaterally, no wheezes/rhonchi/rales.

Heart – RRR, no murmurs, click or rubs.

Abdomen –Soft, NT/ND, BS present, no hepatosplenomegaly, no CVA tenderness.

Musculoskeletal –FROM of upper and lower extremities.

Neurologic – Awake, alert and follows commands, no focal motor deficit. Sensation intact to touch in bilateral upper and lower extremities.

Peripheral Vascular – Varicose veins noted bilaterally. No leg swelling. Pulses are 2+ bilaterally in upper and lower extremities.

DDx:

• Thrombophlebitis
• Cellulitis
• DVT

Assessment and Plan:

70 yo female with PMH of HTN, GERD, varicose vein c/o redness over her left calf x 2 weeks, improved with compression stocking. Physical exam of the left calf reveals a small area of erythema and induration over a distended vein. The area is warm and tender to palpation. No signs of trauma. Well’s score for DVT is 1. Symptoms most likely caused by thrombophlebitis, need to r/o DVT.

# Thrombophlebitis vs. DVT

• Explained to the patient that given its placement, she will need to go to ER for US imaging to r/o clots, but patient refuses.
• Discussed risks of delayed care including risk of pulmonary embolism. Patient verbalizes understanding and reports will call vein clinic to see if she can make outpatient US appointment. She reports if unable to get appointment, will go to ER.
• Strict ER precautions given including SOB, palpitation, cough, chest pain or other change in symptoms.