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Diagnosis #1

History Finding(s)
Physical Exam Finding(s)

Diagnosis #2

History Finding(s)
Physical Exam Finding(s)


Diagnosis #3

History Finding(s)
Physical Exam Finding(s)

Diagnostic Study/Studies



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Doorway information:

Rachel Geller, a 40-year-old female, presents to the emergency room with complaints of right calf pain.

Vital Signs:

Blood Pressure: 122/70 mm Hg

Temperature: 100.0oF (37.8oC)

Heart Rate: 80/minute, regular

Respirations: 14/minute

Chief complaint Location: Right calf pain
Intensity: 7/10
Constant/Intermittent: Constant
Quality: Sharp & throbbing
Onset : 4 days ago, getting worse
Radiation: No
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
Chest pain:No
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 falls:No
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
Drug allergies:None
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.
Occupation:Pharmaceutical Sales
Alcohol use:Seldom, on holidays
Tobacco use:No
Drug use:No
Sexual activity:With my spouse

Exam:

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

Instructions

  1. Obtain a history pertinent to this patient’s problem.
  2. Perform a relevant physical examination (Do not perform a breast, pelvic/genital, corneal reflex, or rectal examination).
  3. Discuss your impressions and any initial plans with the patient.
  4. After leaving the room, complete your patient notes on the given form or computer.

Closing

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?

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