AC H&P 2

Chief Complaint:
“Swelling and pain in my right leg” x 5 days

History of Present Illness:
A 39-year-old male with a history of hypertension presents with a 5-day history of increasing swelling, redness, and pain in his right leg. The patient states that symptoms started with a small scratch on the anterior shin, which became red and tender. Over the past several days, the area of redness has expanded, and the leg has become increasingly swollen and warm to the touch. He describes the pain as constant, throbbing, and a 6/10 in intensity. The patient denies any drainage from the area, fever, or chills but reports difficulty walking due to discomfort. He has been taking ibuprofen with minimal relief. Denies insect bites, or recent travel.

The patient admits to working as a construction laborer and notes frequent kneeling and minor cuts/scratches on his legs due to his job. He denies any known allergies. He is uncertain about his tetanus vaccination status but believes he had his last shot several years ago.

Past Medical History:

  • Hypertension (controlled with medication)

Past Surgical History:

  • None

Medications:

  • Lisinopril 10 mg PO daily

Allergies:

  • No known drug allergies
  • No known food or environmental allergies

Family History:

  • Mother: Alive, history of hypertension
  • Father: Deceased, heart disease
  • Siblings: One sister, alive and well
  • Maternal grandparents: Unknown
  • Paternal grandparents: Unknown

Social History:

  • Smoking: Non-smoker
  • Alcohol: Drinks socially, 2-3 beers per week
  • Drug use: Denies recreational drug use
  • Caffeine: 1 cup of coffee daily
  • Occupation: Construction worker
  • Living situation: Lives alone in an apartment

Review of Systems:

  • General: Denies fever, chills, night sweats, or unintentional weight loss.
  • Skin: Admits to redness, swelling, and warmth in the right leg. Denies other rashes, itching, or skin breakdown.
  • Head: Denies headaches, trauma.
  • Eyes: Denies vision changes, redness, or discharge.
  • Ears: Denies pain, discharge, or hearing loss.
  • Nose: Denies nasal congestion or epistaxis.
  • Mouth/Throat: Denies sore throat or lesions.
  • Neck: Denies stiffness or swelling.
  • Cardiovascular: Denies chest pain, palpitations, or lower extremity edema (other than right leg swelling).
  • Pulmonary: Denies cough, shortness of breath, or wheezing.
  • Gastrointestinal: Denies nausea, vomiting, or abdominal pain.
  • Genitourinary: Denies dysuria, hematuria.
  • Musculoskeletal: Admits to pain and swelling in the right leg, denies other joint pain or swelling.
  • Nervous System: Denies weakness, numbness, or tingling.
  • Peripheral Vascular: Admits to localized swelling and redness in the right leg. Denies other color changes or edema.
  • Hematologic: Denies easy bruising or prolonged bleeding.
  • Endocrine: Denies polyuria, polydipsia, or heat/cold intolerance.
  • Psychiatric: Denies anxiety or depression.

Physical Exam:

  • Vitals:
    • BP: 138/85 (seated, right arm)
    • HR: 86 BPM (regular)
    • RR: 18/min (unlabored)
    • T: 98.6 F (oral)
    • O2: 98% (room air)
    • Height: 5’11” Weight: 240 lbs BMI: 33.4
  • General:
    • Alert and oriented x 3, appears in mild discomfort due to leg pain. Well-nourished, well-groomed.
  • Skin:
    • Right lower leg: Significant erythema, warmth, and swelling from mid-shin to ankle. Tenderness to palpation, especially along the anterior tibia. No open wounds or drainage noted.
  • Head:
    • Normocephalic, atraumatic.
  • Eyes:
    • PERRLA, conjunctiva pink.
  • Ears:
    • TMs intact bilaterally.
  • Nose:
    • No nasal discharge or obstruction.
  • Mouth:
    • Oral mucosa pink, moist, no lesions.
  • Neck:
    • Supple, no lymphadenopathy.
  • Cardiovascular:
    • RRR, S1/S2 normal, no murmurs, rubs, or gallops.
  • Pulmonary:
    • Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
  • Abdomen:
    • Soft, non-tender, no guarding or rebound.
  • Musculoskeletal:
    • Full range of motion (FROM) in bilateral upper and lower extremities, except for discomfort on flexion and extension of the right ankle due to pain. No deformities noted.
  • Peripheral Vascular:
    • Right lower leg: Mild pitting edema present, pulses 2+ in dorsalis pedis and posterior tibial arteries. No cyanosis or clubbing. Left lower extremity without edema, pulses 2+ bilaterally.
  • Neurological:
    • Sensation intact bilaterally in lower extremities. Strength 5/5 bilaterally.

Assessment:
39-year-old male with a 5-day history of progressive swelling, erythema, and pain in the right lower leg consistent with acute cellulitis, likely secondary to a superficial skin abrasion. No evidence of systemic involvement at this time.

Differential Diagnosis:

  1. Cellulitis
  2. Deep vein thrombosis (DVT)
  3. Venous stasis dermatitis

Plan:

  1. Diagnostics:
    • Venous Doppler of right leg to rule out DVT.
    • CBC, CMP to assess for signs of infection or metabolic abnormalities.
  2. Treatment:
    • Antibiotics:
      • Oral Cephalexin 500 mg, 1 tablet every 6 hours for 10 days.
    • Pain management:
      • Ibuprofen 600 mg PO every 6 hours as needed for pain.
    • Elevation and Compression:
      • Patient advised to keep the leg elevated as much as possible and to apply compression with an elastic bandage to reduce swelling.
  3. Patient Education:
    • Importance of completing the full course of antibiotics.
    • Monitoring for signs of worsening infection (e.g., increased redness, warmth, fever, or spreading of the infection).
    • Return to the clinic if symptoms worsen or fail to improve after 48-72 hours.
    • Encourage proper wound care and hygiene at work.
  4. Follow-Up:
    • Recheck in 1 week or sooner if symptoms worsen.
    • Immediate care if signs of systemic infection (e.g., fever, chills, or increased swelling) develop.