CHIEF COMPLAINT: Left thigh pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female with a history of blood clots who presents to the emergency department from the doctor’s office for a Doppler study to rule out DVT. The patient states she has had some left thigh pain that began this morning. The patient describes the pain as an ache to her left inner thigh. It seems to be worse with movement of her thigh. She denies any injury or trauma to the thigh. She is able to bear weight on the left lower extremity. The patient denies any edema, erythema, warmth to touch or deformity. The patient was actually seen and evaluated by the doctor today, and he was concerned that she may have another DVT, so he sent her here for a Doppler study. The patient is on Coumadin already and has been taking it appropriately. She denies any dizziness, lightheadedness, headache, blurred vision, neck pain or stiffness, fever or chills, shortness of breath, chest pain, palpitations or cough, abdominal pain, nausea, vomiting, diarrhea, bowel or bladder symptoms or incontinence, back pain or paresthesias.
PAST MEDICAL HISTORY:
1. Cirrhosis.
2. Hemochromatosis.
3. Blood clots.
CURRENT MEDICATIONS: Kristalose, Lasix, Natacyn, Aldactone, Protonix, Celexa, Coumadin, Depakote, Ativan, and Midrin.
ALLERGIES: IMITREX AND IBUPROFEN.
SOCIAL HISTORY: Unremarkable.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 106/50, pulse 104, respirations 18, temperature 98.2, and O2 saturation 98%.
GENERAL: The patient is alert and oriented x3, in no acute distress, nontoxic in appearance, is ambulatory in the emergency department.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Positive bowel sounds in all 4 quadrants. Obese, soft, nontender, nondistended, no rebound, no guarding.
BACK: Negative CVA tenderness.
EXTREMITIES: The patient has 2+ pulses in all extremities. The patient has some tenderness to palpation of the anterior inner left thigh. There is no erythema, edema, warmth to touch or deformity noted. Full range of motion of bilateral hips, knees, ankles and feet, 2+ dorsalis pedis and tibial pulses of bilateral lower extremities, 5/5 strength lower extremities. No clubbing, cyanosis or edema noted. No asterixis noted.
NEUROLOGIC: Deep tendon reflexes, sensory, motor intact of all extremities. Again, no asterixis noted.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: Renal, coags, and vascular study were done here in the emergency department.
LABORATORY DATA: Renal: Sodium 140, potassium 3.5, chloride 108, bicarbonate 24, BUN 11, creatinine 1.2, glucose 98, anion gap 11. PT, PTT, and INR are pending. Doppler study of the left lower extremity showed no evidence of SVT, DVT of the left lower extremity.
IMPRESSION: The patient is a (XX)-year-old female with left leg pain and left thigh pain. No injury or trauma. It is negative for DVT here in the emergency department. As long as coags are coming back within acceptable range, the patient will be discharged to home.
DIAGNOSIS: Left leg pain.
PLAN: The patient is to rest, ice, elevate. She can take Tylenol for pain. She can follow up with Dr. John Doe next week as long as coags are within acceptable range. If redness, swelling or worsening, the patient is told to return to the emergency department.
DISPOSITION: The patient will be discharged in stable condition.
