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Name: V.NDate: 8/23/2020Time: 0800
Age: 53 yearsSex: Male
SUBJECTIVE
CC: “I am having pain in my right leg”
HPI: The patient states that the pain started four days ago and it is in the right lower leg. The patient states that his right leg feels tight and he rates the pain as 7/10
Medications:None
PMHNo past medication history indicated by the patientAllergies: NKDAMedication Intolerances: Denies any intolerance to the medicationChronic Illnesses/Major traumas Denies having any chronic diseasesHospitalizations/Surgeries: Denies any surgical procedure or hospitalization
Family HistoryFather is having cardiac heart failure related disease while the mother is having high blood pressure
Social History The patient is a university graduate and he is married with two children. He denies taking alcohol or smoking.
ROS
GeneralThe patient denies weight change, fatigue, fever, chills, and the night sweats.CardiovascularThe patient denies pain in the chest, no orthopnea, no palpitations.
SkinDenies any delayed process of healing, bruises, rashes, bleeding or discoloration of the skin, and any moles or lesionsRespiratoryNo coughing, no pneumonia, no wheezes, no dyspnea, no hemoptysis
EyesDenies corrective lenses, no blurring, no changes in her vision.GastrointestinalDenies abdominal pain, no constipation, no history or present hepatitis, no ulcers, denies black tarry stools
EarsDenies pain of the ear, hearing problem, ringing of the ears, or any ear dischargeGenitourinary/GynecologicalPatient denies the presence of the urge or frequency burning, denies change in the urine color and any menstrual issue. Admits to be sexually active. Denies having been diagnosed with STDs
Nose/Mouth/ThroatDenies sinus issues, dysphagia, nose bleeding, discharges, dental illness, hoarseness, pain.MusculoskeletalAdmits swell near his right leg which is painful and tight. Denies history of fracture or osteoporosis.
BreastDenies any changes or bumpsNeurologicalThe patient denies syncope, seizures, short-lived paralysis, weakness, paresthesias, or black-out spells.
Heme/Lymph/EndoThe patient is HIV negative. He denies bruises, has undergone blood transfusion, no night sweats, has swollen glands, increased hanger, denies thirst, cold and heat intolerance.PsychiatricDenies sleeping problems, anxious, and suicidal thoughts or attempts.
OBJECTIVE
Wt 68kg BMI 18.7Temprature 97Blood Pressure 122/62
Ht 6’3’’Pulse 68 beats/minRespiration 16
General Appearance The patient looks well in no acute distress. He is alert and oriented and is responding to the questions in appropriate manner.
SkinThe patient is brown, warmer, clean, and intact. Absence of the lesions or rash
HEENTNormocephalic, atraumatic and with no lesions of the head. The hair of the patient is evenly distributed.Eye is having intact EOMs with no injection of the conjunctival or scleral.Ear is having patent canals, easily visualized landmarks, and the bilateral TMsNose pink mucosa with normal turbinatesNeck is supple without palpable lymphadenopathy, there is no occipital nodes, nodules, nor thyromegaly.There is moist and pink oral mucosa. The pharynx is non-erythematous with no exudate. The teeth is in good shape with normal dental arrangement
Cardiovascular Normal S1 and S2 with regular rate and rhythm. No splitting in the heart sounds heard. No murmur. No friction rub, no edema.
RespiratoryThere is stable, regular, and easy respiration. The auscultation of the bilateral lungs is clear.
GastrointestinalNo obese, active BS in all the four quadrants, soft and non-tender abdomen, and no hepatosplenomegaly.
BreastNo masses or tenderness of the breast. Absence of the discharge and dimpling, wrinkle, and skin color is the same
GenitourinaryBoth testes are palpable, no masses or lesions, no hernia, no urethral discharge. prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm
MusculoskeletalThere is no full ROM in the patient’s extremities. The movement is limited
NeurologicalThe patient is having clear speech, good tone with no erect posture. There is unstable balance and abnormal gait.
PsychiatricHe is alert and oriented, clean, able to maintain eye contact, soft speech, and appropriately responding to the questions asked.
Lab TestsUrinalysis – pendingUrine culture – pendingWet prep – pending
Special TestsComplete blood count: to help in the knowing the number of leukocytesMRI: to detect the presence of thrombusD-dimer: to help in excluding thromboembolic illness
Diagnosis
Differential DiagnosesDeep Venous Thrombosis: it is characterized by pain and the swelling of the limb that is non-specific. The patient have warm, swollen, and tender leg.Cellulitis: this is a non-necrotizing inflammation of the skin and the subcutaneous tissues. It has symptoms such as swelling, warmth, pain, and erythemaPulmonary Embolism: occurs as a result of the blood clot clogging in an artery in the lung and blocking the flow to the lung.Diagnosiso Deep Venous Thrombosis
Plan/Therapeutics
o Plan:· Further testing: ultrasound to see clear picture of the arteries and the veins to monitor how the blood flows. Venogram can also be ordered to be followed by the x-ray to determine the location of the DVT· Medication: Painkillers such as acetaminophen; heparin, lovenox, arixtra, and warfarin to help in the thinning of the blood. Thrombolytic drugs are also prescribed to help in the breaking of the clots.· Education: The patient is advised not to sit for long to reduce the development of the blood clots. The patient is advised to adopt exercise such as knee pulls that involves the bending of the leg and raising of the knee towards the chest. The patient is also taught on the importance of ankle circles exercise where the feet are lifted off the floor while the patient tries to draw the circle with the toes in one direction for a few seconds· Non-medication treatments: Keeping of the arm elevated through the use of the stool or chair. Wearing compression stockings to help in the prevention of pooling and swelling. It also helps in increasing the blood flow.
Evaluation of patient encounter: The patient is evaluated based on the reduction of the pain and the ability to make movement with a lot of ease after discharge from the facility

References

Murrell, D. (2019, November 13). Everything You Want to Know About Deep Vein Thrombosis (DVT). healthline: https://www.healthline.com/health/deep-venous-thrombosis Ouellette, D. R. (2019, October 16). Pulmonary Embolism (PE). Medscape: https://emedicine.medscape.com/article/300901-overview

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