History and Physical
NAME: Jack Black DOB: 03/28/1948 SEX: Male
RACE: Caucasian Physician: Dr. L DATE:
CHIEF COMPLAINT: Right leg pain and swelling with intermittent chest pain x 1 month.
HISTORY OF PRESENT ILLNESS: This is a 62 year old male presenting with right lower extremity swelling and calf pain with intermittent chest pain for approximately 1 month. He states that the swelling and pain has decreased, but is still present. The pain is only present upon compression or movement of the extremity, not constant as it was previously. He also states that he noted that his right foot was a blue color a few weeks ago. He also complains of “achy” substernal intermittent chest pains that began around the time his leg became swollen. He states that pain occurs at rest and is of gradual onset, usually 1-2 times per day, every other day. He states that the pain lasts 15-20 minutes and is resolved spontaneously. He rates the pain as a 5/10. He denies shortness of breath, wheezing, hemoptysis, cough, fever or chills, palpitations, dizziness/lightheadedness, headaches and any skin lesions or ulcers. He states he has been feeling more fatigued than usual lately. He also complains of increased sanguinous and fecal discharge from his abdominal fistulas in the past few days and periumbilical abdominal pain that has been constant for 4 years and has not changed in nature or intensity. He also states he has been experiencing unintentional weight loss over the past few weeks. He denies nausea, vomiting, and diarrhea. He states he has no change in his appetite, no change in bowel movements or blood in his stool.
PAST MEDICAL HISTORY: Abdominal fistulas s/p umbilical hernia repair in 2005 and anemia.
MEDICATIONS: multivitamins, methadone and oxycodone.
SURGERIES/HOSPITALIZATIONS: umbilical hernia repair in 2005 and 2 past hospitalizations for anemia secondary to abdominal fistulas.
SOCIAL HISTORY: Denies tobacco use and drug use, drinks alcohol socially. Patient lives at home with his wife, Active, Works at ScrantonRoofingPros.com
FAMILY MEDICAL HISTORY: no related family history.
REVIEW OF SYSTEMS:
- General: increased fatigue, unintentional weight loss, no fever, chills or sweats.
- SKIN: no ulcers of lesions on extremities.
- HEENT: denies any URI symptoms, eye pain or pressure, visual changes, hearing difficulty, dizziness or vertigo and headaches.
- Cardiovascular: + chest pain + pedal cyanosis + edema of right lower extremity + increased fatigue. Denies dizziness, LOC, palpitations, orthopnea or PND.
- Respiratory: Denies shortness of breath, wheezing, cough, hemoptysis. No history of tobacco use.
- GI: + periumbilical abdominal pain and increased discharge from abdominal fistulas. Denies nausea, vomiting and diarrhea. No appetite change or change in bowel movements, no melena or hematochezia.
- GU: denies dysuria, hematuria, urgency, frequency, or nocturia.
- Neuro: denies memory problems, syncope, weakness, tremors, lightheadedness/dizziness, difficulty walking, changes in hearing, and headache. Denies paresthesias.
- Vital Signs: P 88 R 18 BP 107/61 T: 98.4 SpO2: 100% on room air.
- General: alert and oriented x3. Well developed/well nourished male in no acute distress, speaking full sentences.
- HEENT: Head-normocephalic, atraumatic; Eyes- PERRLA, EOM-intact, conjunctival pallor, no scleral icterus. Ears- intact, no discharge; Nose- patent, no discharge.
- Skin: warm and dry, mild pallor and ecchymosis. No cyanosis, rashes, or ulcers.
- NECK: supple, symmetric, trachea midline, no adenopathy, full ROM, no JVD.
- CHEST: stable, equal rise and fall, no retractions, no instability or crepitus. Non-TTP. No accessory muscle usage.
- LUNGS: Clear to auscultation bilaterally, equal breath sounds. No wheeze, rhonchi or rales. No pericardial friction rub, normal respiratory effort.
- CVS: regular rate, regular rhythm, no murmurs, rubs, or gallops. 2+ radial pulses bilaterally, 2+ femoral, posterior tibial and dorsalis pedis pulses bilaterally. + non-pitting edema in right lower extremity.
- Abdomen: soft, non-distended, tender to palpation periumbilically with involuntary guarding. 4 approximately 2-4 cm diameter abdominal fistulas, with peripheral erythema and sanguinous and fecal discharge. Bowel sounds present and normoactive in all 4 quadrants, no organomegally or masses. No abdominal jugular reflex.
- Extremities: no obvious deformities. Delayed capillary refill. Full ROM. Sensation intact. + non-pitting edema in right lower extremity. + Homan’s sign, + calf tenderness. Non-tender in popliteal space.
- Neuro: Cranial nerves II-XII grossly intact. Mental status: alert and oriented x 3. Sensation intact. 4/5 motor strength bilaterally. GCS of 15.
- Chemistry (CMP)
- K: 3.7, Na: 139, Cl: 105, HCO3: 23, BUN: 14, Cr: 1.1, Glucose: 94.
- WBC: 5.4, Hgb: 5.5, Hct: 20.3, Plt: 599
- CPK-30 Troponin- <0.30
- PT- 1 INR-1.1
- D-dimer: 804
- Type and screen
- Doppler U/S of right leg- + DVT
- CXR- No cardiomegally. Normal pulmonary vasculature, no evidence of interstitial edema. No pleural effusion or infiltrates. No evidence of pulmonary embolus.
- EKG- normal sinus rhythm with a rate of 80 beats per minute. Normal axis. No QT prolongation. No ST or T wave changes. No evidence of PE (S in I, Q in III, inverted T wave in III)
Right lower extremity swelling/pain and chest pain
- DVT/Pulmonary Embolus
- Myocardial Infarction
- New onset CHF
- Chronic Abdominal Fistula
1.) Obtain IV access and Heparin Lock IV
2.) Type and Cross
3.) 2 units PRBCs- 1 unit over 2 hours
4.) Arixtra (fondaparinux) 7.5mg SC
5.) Surgery consult for abdominal fistulas
6.) Admit to internal medicine