PATIENT PRESENTATION Chief Complaint “I’m having pain in my leg.” HPI Rodney Cross is a 51-year-old Caucasian man who presents to his
primary care physician because of pain in his right leg. He states
that he awoke with the pain 3 days ago and that it has been
continuous, although it hurts more when he walks. The pain is
located behind his right knee and extends down into his calf. He
rates the pain intensity as 3/10 at this time. The patient denies
CP and SOB. He denies recent travel, immobility, and leg injury.
The patient started atorvastatin 40 mg daily for treatment of
dyslipidemia approximately 3 months prior to this visit. He stopped
the atorvastatin 3 days ago because he thought it might be causing
his leg pain, but the pain has continued. PMH Hypertension Dyslipidemia Graves disease with thyroid ablation Gout Left ankle fracture 9 years ago that required a cast but no surgery
Remote history of depression PSH Left herniorrhaphy about 10 years ago. Pilonidal cyst excision
in remote past. FH Father died at age 81 of liver failure. Mother, one brother, and
son all alive and well. No family history of venous thromboembolism
or clotting disorders. SH Married, one adult child. Drinks one to two alcoholic beverages
daily. Smokes 1⁄2 pack per day of cigarettes but trying to quit.
Denies illicit drug use. Meds Allopurinol 300 mg PO once daily Lisinopril 10 mg PO once daily
Levothyroxine 150 mcg PO once daily Aspirin 81 mg PO daily Atorvastatin 40 mg PO once daily (discontinued 3 days ago) All NKDA ROS Constitutional: No chills, no fatigue. Eyes: No eye pain or changes in vision. ENT: No sore throat. Skin: No pigmentation changes, no nail changes. Cardiovascular: No CP, palpitations, or syncope. Respiratory: No cough, SOB, wheezing, or stridor. GI: No abdominal pain, nausea, diarrhea, or vomiting. Musculoskeletal: No neck pain, back pain, or injury. Neurologic: No dizziness, headache, or focal weakness.
Psychiatric/behavioral: Remote history of depression. Not a current
problem. Na 140 mEq/L K 3.9 mEq/L Cl 103 mEq/L CO2 27 mEq/L BUN 10 mg/dL SCr 0.84 mg/dL Glucose 88 mg/dL Uric acid 5.0 mg/dL WBC 5.9 × 103/μL RBC 4.28 × 106/μL Hgb 13.5 g/dL Hct 39.3% Platelets 175 × 103/μL CK 117 IU/L INR 1.0 PT 11.4 seconds aPTT 34.8 seconds AST 16 IU/L ALT 20 IU/L Alk phos 67 IU/L GGT 20 IU/L Lipid panel (fasting) TC 180 mg/dL HDL 30 mg/dL Trig 250 mg/dL LDL 100 mg/dL 1.a. What subjective and objective information indicates
the presence of DVT? 1.b. What additional information is
needed to fully assess this patient? 2.a. Assess the severity of an acute DVT based on the
subjective and objective information available. 2 . b. Create a list of the patient’s drug therapy problems
and prioritize them. Include an assessment of medication
appropriateness, effectiveness, safety, and patient adherence.
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