Mr. Franco, 46 years old, male, Caucasian. Divorced. Working
from home as a computer programmer. Awake, alert, and oriented.
Appropriately asks and responds to questions. “I have pain in my right lower leg. There is soreness, some pain
and swelling. It hurts more when I walk.” Right calf pain and swelling began 3 days
ago. Reports discomfort increases when walking. Swelling and pain
improves when leg is elevated. Reports no color or temperature
changes in arms or left leg, no pain in left leg but reports
having mild to moderate pain in right lower leg especially when he is
up and moving around. States has taken acetaminophen 1000 mg 2 –3
times per day to relieve leg pain. Reports concern that he may have
thrombophlebitis and recounts his prior history of pulmonary
embolism following surgery. Has hypertension and hyperlipidemia, both controlled by
medication. Obese but otherwise no major health problems. No food
or medication allergies. After coronary artery bypass graft (CABG)
5 years ago, has had no further problems with angina. No other previous surgeries on veins or arteries. Reports having
an appendectomy at age 12. Mother has hypertension and his father’s
brother died from complications of diabetes. Uncertain of other
family history of clotting disorders, diabetes, or history of
cardiovascular disease. States does not smoke, and that he does manage his stress well,
drinks an occasional beer 2–3 times per week with friends, no
recreational drug use, and exercises by walking a few blocks most
days. Lives on the second floor of an apartment building. Reports
sitting for hours at computer with few breaks. Occasionally
remembers to exercise feet and lower legs. States he most often
takes the elevator because he becomes short of breath when takes
the stairs. Denies leg pain with walking or when taking the stairs.
Tries to follow a low-fat diet to lower cholesterol but states
he finds it difficult to follow dietary restrictions. States he
knows he needs to be more active and lose some weight. Denies
problems with sexual activity. Alert, oriented with no shortness of breath or chest pain. T,
97.9; P, 88; R, 12; BP, 144/86. Skin warm, dry, pink, and intact. Color and
temperature same bilaterally in upper extremities with strong
radial pulses, no edema. Capillary refill rapid bilaterally in
fingers. Bilaterally strong femoral and popliteal pulses. Presents
with right calf swelling and is red, warm, and tender to touch as
compared to left leg. Right calf measures 42 cm, while left calf is
34.5 cm. Dorsalis pedis and posterior tibial pulses strong and
equal bilaterally. No edema in ankles or feet; warm, pink skin
color with rapid capillary refill. No pain in left leg but on a
0–10 point scale, reports a 4 rating presently in right lower leg,
no ulcerations or discoloration of skin on legs. Normal hair
pattern distribution on lower extremities. No distended veins or
swollen glands detected. Think back of the case. Document the following subjective and
objective assessment findings based on Mr. Franco Physical
examination. Answer the ff: 1.
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