CHIEF COMPLAINT: Left calf pain.
SUBJECTIVE: The patient presents to the office today. She is a (XX)-year-old female with left calf pain. She had been complaining of left knee pain since MM/DD/YYYY injuring it while walking on a treadmill. She had an MRI ordered in March by Dr. John Doe and it did show a displaced complex tear of the medial meniscus.
She was referred to Dr. Jane Doe and underwent left knee arthroscopy approximately 2 months ago. Two weeks prior, she had “charley horse” on the left calf that was quite painful. She was then walking last night and she felt a “pop.” The pain radiated from that left calf to the left popliteal fossa and left foot.
She also noted some increased swelling recently, was wearing a left lower extremity TED hose. She did not take any anti-inflammatories for this recently and she has an allergy to NSAIDS.
Her past medical history includes left knee medial meniscus posterior horn and body tear, elevated blood pressure, obesity, generalized anxiety disorder, benign paroxysmal positional vertigo with Meniere’s disease.
OBJECTIVE:
VITAL SIGNS: Afebrile, pulse 86, blood pressure 134/80, and weight 268 pounds.
GENERAL: In no apparent distress. A pleasant, awake, alert and oriented x3 morbidly obese white female.
HEENT: Normocephalic and atraumatic. Extraocular muscles are intact. Oropharynx is clear. Moist mucous membranes. Dentition is intact.
NECK: Supple without anterior cervical or supraclavicular adenopathy. No JVD, bruits or thyromegaly.
HEART: Regular rate and rhythm without murmurs, rubs, gallops or thrills. PMI is normal.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi. Trachea is midline.
ABDOMEN: Soft, nontender and nondistended. No hepatosplenomegaly. Positive bowel sounds in all 4 quadrants without rebound, guarding or rigidity.
EXTREMITIES: No clubbing, cyanosis or edema on the right side. She has some varicosities noted. Left shows trace to 1+ edema. Calf diameter is equal at 19.5 inches bilaterally. She does, on the left calf, have some palpable, either musculature or questionable thrombophlebitis in the posterior aspect of the left calf, just distal to the left popliteal fossa. She has 2+ dorsalis pedis pulses bilaterally. Gait is antalgic with a short stance phase on the right.
ASSESSMENT:
1. Left calf pain.
2. Recent left knee arthroscopy secondary to medial meniscal injury.
PLAN: The patient will be approached with left lower extremity Doppler today, calling me with results. Certainly, deep vein thrombosis needs to be ruled out. She could have a musculotendinous tear in that areas as well related to her activity and exertion.
If this is negative, then we will setup for PT/OT regimen. If this is possible, we will certainly treat DVT acutely and contact Dr. Jane Doe’s office, at least making her aware. She understands the importance of this followup, and we will have them call us with the results of the lower extremity Dopplers today.
