History of Present Illness:

70 y/o F, with a PMHx of HTN, HLD and cocaine abuse, who presents to the ED c/o left lower leg pain and swelling for two weeks. Patient states she was at her PCP discussing this issue, who sent her to the ER. She describes the pain as sharp, stabbing and burning sensation and states it is most intense behind her left knee. She reports alternating between Motrin and Tylenol, with minimal relief, and also reports to using Biofreeze and Lidocaine patches to try to relieve the pain. She states she has difficulty ambulating and standing secondary to the pain, which is not her normal. Patient states the pain is more than a 10/10. She denies any recent travel, sick contacts or falls. She denies fever, chills, chest pain, palpitations, shortness of breath, cough, abdominal pain, nausea, vomiting or dizziness.

PMHX: HTN, HLD, cocaine abuse, depression, diet-controlled diabetes

PSHx: none

Medications: Gabapentin 100 mg one capsule PO three times a day, Citalopram 20 mg one tablet PO daily, Seroquel 50 mg 1 tablet PO nightly, Flexeril 5 mg one tablet PO two times a day for up to 10 days, ASA 81 mg daily, Amlodipine 2.5 mg one tablet PO daily

Social History: cocaine abuse 2x/week x 40 years, cigarette use 2x/week x 25 years, alcohol use once every few months

FMHx: Denies known history of blood clots or clotting disorders

Allergies: NKDA

Review of Systems:

Gen: Denies fever, chills, night sweats, fatigue or weakness

Skin: Denies rashes or discolorations

Resp: Denies cough, shortness of breath, wheezing, hemoptysis

CV: Admits to left lower extremity swelling and pain. Denies chest pain, palpitations.

GI: Denies abdominal pain, nausea, vomiting, diarrhea

GU: Denies dysuria, hematuria, urgency

MSK: Admits to LLE pain. Denies back pain.

Neuro: Denies weakness, dizziness, headaches

Physical Exam:

VS: T 98.2 F, BP 148/68, HR 80, RR 18, O2 saturation 98% on room air, Wt 172 lb, Ht 5’4”, BMI 29.5

Gen: Alert and oriented, in no acute distress. Not toxic or ill appearing. Mildly anxious

Skin: Warm and dry. No discolorations, warmth or redness to LLE.

HEENT: Normocephalic, atraumatic. PERRL. Mucous membranes moist

Resp: Clear to auscultation bilaterally

CV: Regular rate and rhythm. No murmurs. DP/PT pulses 2+ bilaterally.

Abd: Soft, nontender, nondistended

MSK: LLE with mild edema and pain to palpation from mid-calf to mid posterior thigh. No ulcers or lacerations. +Homans sign on left lower extremity.

Differentials: leg sprain, leg strain, DVT, superficial vein thrombosis, Baker’s cyst

Assessment:

70 y/o F, with a PMHx of HTN, HLD and cocaine abuse, who presents to the ED c/o left lower leg pain and swelling for two weeks. In no acute distress, afebrile with LLE posterior pain to palpation and swelling with intact pulses and no color changes.

Plan:

CBC

BMP

PTT/PT

US LLE Doppler

Toradol IV

Addendum:

Patient’s pain and symptoms improved with IV Toradol.

CBC 11.2, RBC 4.73, HGB 13.9, HCT 42

PTT 43.3, PT 12.7, INR 1.1

Sodium 139, K 4.2, Cl 105, CO2 25, BUN 20, creatinine 0.7, glucose 202, calcium 9.1, anion gap 8, osmolality 296

US: No evidence of DVT in LLE. Fluid imaged within the suprapatellar soft tissues and medial to the popliteal fossa may or may not communicate with the knee joint.

Disposition:  

Patient will be discharged at this time as she has no evidence of DVT on ultrasound.

Patient Education:

You have pain in your left lower leg. This is not a deep vein thrombosis, as we did an ultrasound, and no clot was seen. You will be referred to the medicine clinic for further evaluation. Keep your scheduled appointment for your knee x-rays. Continue to take Motrin and Tylenol for your pain as needed. Return to the emergency department for new or worsening symptoms including discoloration to your left leg, increased swelling or pain, chest pain, shortness of breath, palpitations, dizziness, fever or chills.