A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
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For the case you have chosen, post in the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
MODEL ANSWER
Healthy/Physical Assessment
Questions I would Ask the Patient
- When did the problem begin?
- Have you had any trauma involving the lower limb?
- Where do you feel the pain?
- Is the pain persistent or intermittent?
- How severe is the pain when walking?
- Does the pain reduce when you take a seat?
- Do you experience pain after prolonged standing?
- Does the pain extend to the buttocks, lower back, and thighs?
- Does the pain improve when you lean forward at the waist?
- How often do you walk or stretch?
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Physical Exam
The goal of conducting a physical examination is | PLACE YOUR ORDER NOW AT writtask.com | and review the patient’s | PLACE YOUR ORDER NOW AT writtask.com | in identifying the pain pattern experienced in the leg and the foot. Moreover, it may help to check related past medical conditions.
During the physical examination, I would check for skin changes and swelling in the | PLACE YOUR ORDER NOW AT writtask.com | should focus on the foot, lower limb, thigh, buttock, and | PLACE YOUR ORDER NOW AT writtask.com | also examine the patient’s response to certain stimuli by pressing the calf region, knee and toes (Stone et al., 2017).
Further Testing
Further testing that will be conducted on this patient include D-dimer blood test, Duplex ultrasound and/or | PLACE YOUR ORDER NOW AT writtask.com | the patient on certain areas such as the ankle and the knee may help in examining joint reflexes. The reflexes will help to examine the strength of muscle and the possibility of various ailments.
SOAP Note
| Pertinent Positives | Pertinent Negatives |
| Recent surgical procedure | No history of lower limb trauma |
| Prolonged sitting or bed rest due to the surgical procedure | No history of recent sport or exercise activity |
| Swelling and warm skin around the painful area. | The patient is not feeling numb or itchy. |
Differential and Working Diagnosis
Differential Diagnosis
- Calf Muscle Cramp
- Calf Muscle Strain
- Calf Muscle Contusion
- Soleus Muscle Strain
- Plantaris Muscle Rupture
- Leg aneurysm
- Baker’s cyst
- Cellulitis
Working Diagnosis
Deep Vein Thrombosis (DVT)
Treatment Plan
The main goals of DVT treatment include preventing the blood clot from increasing in size, reducing the possibility of the clot moving to the lungs as well as minimizing the possibility of | PLACE YOUR ORDER NOW AT writtask.com | options include anticoagulants (blood thinners) to prevent the clot from getting bigger as well as minimize the possibility of developing multiple | PLACE YOUR ORDER NOW AT writtask.com | of the condition, clot busters may also be recommended. Additionally, anti-inflammatory drugs may help relieve the pain and reduce the | PLACE YOUR ORDER NOW AT writtask.com | may also use OTC and complementary therapy, including stretching and strengthening the muscle through doing calf stretches and heel raises. Moreover, they should take a rest and probably use ice packs to minimize swelling and muscle pain (Ramondou et al., 2020).
Health Education and Lifestyle Changes
Always warm-up and stretch the calf muscle before undertaking physical | PLACE YOUR ORDER NOW AT writtask.com | cool down after the | PLACE YOUR ORDER NOW AT writtask.com | should stay hydrated and avoid engaging in aggressive activities, especially after a surgical operation.
Age-Appropriate Preventive Care To prevent the non-muscle related sources of calf pain such as claudication and blood clots, it is important to observe measures that may reduce such…
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