Identifying Data Pt is an 80 years old male, single, Hispanic/Latino who was admitted to emergency room secondary to acute pain and swelling in the right lower extremity with emphasis in the calf region. Chief complaint R LE pain and swelling Pt complaint of 9/10 pain and stated: 1. “I was washing TV when I felt persistent cramps on My R calf” 2. “I couldn’t get out of the chair and my lower leg became warm and swollen” HPI Pt presented with severe inflammation, tenderness, redness and warm temperature in the right lower extremity specifically in the calf region improving with ice and elevation and worsening when palpating or digging into the area.
Pt stated his symptoms started 8 hours ago. Pt had a R CVA a year ago with L hemiparesis and required maximal assistance for functional mobility. Since then, pt. has been bed bound with decreased mobility and ambulation. Pt with history of blood clots was resting at home washing TV when started feeling this severe calf pain cramp-like and immediately asked for help. His supportive daughter called emergency services to transfer pt. to ER. Reviewed systems Constitutional: Pt denies: fever, generalized weakness, malaise, chills, fatigue, lethargic or recent weight lost.
Integumentary: Pt denies ecchymosis, abrasion, laceration, bruising, contusion, diaphoresis, rash; itching however reports redness and warmth in the R LE. Respiratory: Pt denies dyspnea on exertion, hemoptysis, nocturnal dyspnea, pleurisy, pneumonia, shortness of breath or wheezing however pt. reports he has been hospitalized a few times due to recurrent chronic bronchitis. Cardiovascular: Pt denies chest pain, palpitations, orthopnea, edema, nocturnal dyspnea however has a history of HTN well controlled with Lisinopril and high cholesterol managed with diet and Gastrointestinal Pt denies: abdominal pain, diarrhea, dysphagia, vomiting, hematemesis, rectal pain, nausea, other.
Genitourinary Pt denies: dysuria, hematuria, flank pain, testicular pain, penile discharge, testicular swelling, urinary retention, nocturia, urgency, other. Musculoskeletal Pt reports pain, redness and warmth in the R LE; reports decreased strength and ROM in the L side of the body after the CVA a year ago; reports severe osteoarthritis in the L hip followed by a THA; denies back pain, joint pain, muscle cramps, neck pain or stiffness, myalgia, trochanteric pain and others.
Eyes Pt denies: redness, blurred vision, diplopia, ocular pain, discharge, swelling, photophobia, other. Ears, nose, mouth, and throat Pt denies: ear drainage, ear ringing, hearing loss, nasal congestion, nose bleeding, sinus problem, vertigo, sore throat, throat pain or swelling, tongue pain, toothache, voice change and other. Neurologic Pt reports inconsistent numbness in the L hand and forearm followed the CVA a year ago; reports L side hemiparesis however denies involuntary movements, syncope or seizures. Psychiatric Pt denies: severe anxiety, nervousness, mood changes, exposure to violence, depression and other.
Endocrine Pt denies: polydipsia, polyphagia, polyuria, changes in the skin, hair and unexpected change in body weight. Heme: Pt denies adenopathy, bleeding, bruising, petechiae, other. Allergic/ Immune Pt denies allergic reaction, hives, sneezing, itching, anaphylaxis, rhinorrhea and other. PMH 1. History of DVT on L LE followed total hip arthroplasty 1. Controlled hypertension 2. High cholesterol 3. Smoking 4. Type 2 diabetes 5. R ischemic CVA one year ago 6.
Chronic bronchitis List surgeries: 1. Total left hip arthroplasty 15 years ago 2. Appendectomy at 12 years old Current Medications: Lisinopril – 20 mg daily Simvastatin- 20 mg at bedside Metformin- Lovenox- 0.4 mg Aspirin- 80 mg daily Pepcid- 20 mg daily Multivitamins Argelies: No known Social history: Pt lives in one story house with supportive daughter and two grandsons. Pt was a bus driver however pt is retired, home bound and has a caregiver 8 hours daily secondary to pt.’s functional decline.
Family history: Father had history of Parkinson’s disease; Mother had type two diabetes and breast cancer. Objective data: Vitals signs: BP: 145/96; HR: 85 bpm; SpO2: 96% RA; Respiratory rate: 16; Temp- 98.5; BMI: 21.75 Height: 5’7 Weight: 170 lb Physical Assessment General appearance: awake, alerted Integumentary: intact skin, dry, redness and inflammation in the R LE. Respiratory: clear to auscultation, no distress, no wheezes, rhonchi or reals. Cardiovascular: normal capillary refill, regular rate and rhythm; radial/carotid arteries normal pulse bilaterally;+2 edema in the R LE, no cyanosis. Abdomen: normal bowel sounds, no distension, no guarding, no mass/organomegaly, no hernia, soft abdomen.
Head/eyes: clear cornea, normocephalic, atraumatic, Ears, nose, throat: normal dentition, normal ear left, normal ear right, normal nose, normal pharynx and normal sinus. Extremities: moves R LE with increased pain, decreased mobility in the L LE due to hemiparesis hence decreased range of motion; increased edema the R LE. Musculoskeletal: overall muscle weakness, positive Homan’s test, R LE edema, warmth, and tenderness; circumferential measurement R LE 3 cm more than L LE. Pt ambulates short distances with maximal assistance and use of assisted device (rolling walker).
Psychiatry: normal affect, normal mood, pleasant, not suicidal, no hallucinations, no homicidal. Neurologic: oriented x3, decreased proprioception, balance and coordination. Concentration is normal; decreased gait quality characterize by step to pattern with maximal assistance. Diagnostic test: US Doppler venus to R LE Assessment: 1. Acute DVT According to physical exam, positive homman test, positive vascular study (ultrasound, Doppler venous) and recurrent history of blood clot pt. has been diagnose with acute occlusive thrombus right popliteal vein. 2. Ischemic stroke (R CVA) Pt presented with history of R CVA and L hemiparesis with decreased mobility and gait. 3. Controlled HTN Pt had a history of high cholesterol and high blood pressure well controlled with Lisinopril.
Plan: 1. Pt will continue with anticoagulants and will benefit from ice, compression and elevation of R LE to decreased inflammation. 2. Pt will begin with acute rehabilitation to increase mobility, ambulation and independence to decreased risk for clots; OT and PT will be ordered for pt. 3. Continue to manage HTN and high cholesterol with medications and diet. Continue with collaboration among Interdisciplinary team. Pt and daughter are in agreement the treatment plan.
