Rachel Geller, a 40-year-old female, presents to the emergency room with complaints of right calf pain.
Blood Pressure: 122/70 mm Hg
Temperature: 100.0oF (37.8oC)
Heart Rate: 80/minute, regular
Chief complaint Location: Right calf pain
Quality: Sharp & throbbing
Onset : 4 days ago, getting worse
Associated symptoms: Some swelling, especially after work
Alleviating factors: Elevating my right leg & Ibuprofen
Aggravating factors:Stretching my leg out Putting pressure on my leg
Shortness of breath:No
History of varicose veins:No
Redness:Looked a little pink to me today
Fever:Last night my temperature was 99.7. I’ve been taking Ibuprofen.
Recent travel:I just came back from a business trip last week.
Recent immobilization:The flight was 10 hours
Past medical history:None
Medications:Birth control pills
Past surgical history:2 C-sections, my kids are 4 and 6
Menstrual history, LMP:3 weeks ago, normal cycles
Family history:My Mom has high blood pressure.
Alcohol use:Seldom, on holidays
Sexual activity:With my spouse
Cardiovascular: Auscultate heart, check pulses
Pulmonary: Auscultate lungs
Abdomen: Palpate, Auscultate
Rheumatology: Examine joints, Range of motion – right calf focus and compare with left calf
Extremities: Homans’ sign
Neurologic: Motor reflexes, sensory
Mrs. Geller, based on the information I’ve gathered, there is a chance you have a blood clot in your leg. Often times, people will develop
these clots due to risk factors such as long travel and certain medications like birth control pills. However, we cannot be sure of this until
we get further testing. There’s also a chance that it’s a skin infection, muscle strain, or even a cyst. If the tests do show a clot, then we
will need to start a medication right away that will thin your blood and dissolve the clot. I know this is a lot of information and seems scary,
but we will do everything to take good care of you. Do you have any questions for me?