DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left leg swollen.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who reports swelling to the left lower extremity for the past couple of days. Apparently, it was noticed by her home care nurse today, who contacted the primary care provider and told her that she should come to the ER and have it checked. There has been no injury to the leg. She says the leg is somewhat sore. She has had no other systemic symptoms. No fevers, chills, upper respiratory congestion. No chest pain. No shortness of breath.
PAST MEDICAL HISTORY: Extensive and includes gastroesophageal reflux disease, diverticular disease, congestive heart failure, atrial fibrillation, prior history of breast and skin cancer, vertebroplasty, and chronic nonhealing wounds to the left lower extremity.
MEDICATIONS:
1. Coreg.
2. Protonix.
3. Isosorbide.
4. Aspirin.
5. Hydrocodone.
6. Vitamins.
7. Ginkgo biloba.
ALLERGIES: The full list of allergies can be found on the chart.
SOCIAL HISTORY: The patient is a nonsmoker and nondrinker. She lives at home.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: All other systems were reviewed and were negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 152/64, temperature 97.4, pulse 62, respirations 18, and oxygen saturation 96% on room air.
GENERAL: The patient is a (XX)-year-old who is awake, alert, calm, cooperative, in no acute distress.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. No nasal discharge. No facial trauma. Intraoral exam shows moist mucous membranes with no tonsillar enlargement or exudate. Tympanic membranes are normal. The canals are clear.
NECK: Supple with no cervical lymphadenopathy. No meningismus. No goiter.
HEART: Regular rate, without murmur, rub or gallop.
LUNGS: Equal breath sounds bilaterally with no wheezing, rales or rhonchi.
CHEST: There is no chest wall tenderness or instability.
ABDOMEN: No external sign of injury. Bowel sounds are present. Abdomen is soft, nontender, no rebound, no guarding, no rigidity. There are no palpable masses. There is no flank pain on exam.
EXTREMITIES: The patient’s left foot shows some erythema and some open, ulcerative type of lesions to the left lower extremity, just above the level of the ankle. There is a little edema present. There is no warmth or skin changes at that location. Pulses are intact. Cap refill is immediate. Overall circulation seems to be intact. The patient has no bony tenderness noted to the ankle or lower extremity.
SKIN: No rash.
EMERGENCY DEPARTMENT COURSE: Here in the emergency room, CBC showed anemia, which is chronic and is consistent with prior labs. D-dimer was elevated but just above 1. We did discuss these findings with the patient and family members. Given her anemia and history of diverticulosis, we were hesitant to anticoagulate her empirically for this and, given the fact that it was almost 11 o’clock in the night, we were unable to get a stat venous Doppler at that point in time. We are going to make arrangements for her to have a venous Doppler of the left lower extremity to exclude DVT in the morning, and because of her other associated risk factors, we are going to withhold anticoagulation at this point in time. The family members seem to understand and are in agreement with that course of action.
FINAL DIAGNOSIS: Edema to the left leg, of unclear etiology.
PLAN:
1. The patient is going to have a vascular Doppler of the left leg in the morning. She was given an order slip for that.
2. Elevate the leg as much as possible.
3. Follow up with Dr. John Doe.
