Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 35 year old female who presents to the clinic with unilateral edema of the right leg. CC is “My right leg is painful and swollen.”
HPI: The patient is unable to bear weight on her leg and says she has not been able to walk on it much since returning from a mission trip in Africa. She reports several lengthy flights during her trip, the longest of which was about 8 hours non-stop. Her leg pain and swelling started a few days after she returned to the United States. She says the pain and swelling are constant; there is no difference in the pain and swelling in the morning as compared to the evening. She denies any contact with animals, recent insect bites, or trauma. She also denies any shortness of breath or chest pain.
PE –
Appearance: A mildly obese female patient with appearance consistent with stated age. Patient is in no distress.
VS: BP 125/85, P 65, RR 18, BMI 30, T 99
Musculoskeletal: Full range of motion of extremities. Right leg is swollen with 2+ pitting edema present to the knee. Erythema of the right calf is present. Right calf is warm and tender to the touch. No erythema or edema noted in the left leg
Labs –
Venous duplex US: DVT present in the right lower extremity – clot present in the tibial vein, extending into the popliteal vein; No DVT present in the left lower extremity.