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History
of Present Illness
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History and Chief
Complaint. A 54-year-old woman presents to the emergency department at
10pm from a local hotel, where she is vacationing three hours' drive from
her home. She complains of atraumatic right leg swelling for the past
three days. Yesterday she began to have some pain in the leg and it limited
her activity. She otherwise feels well and is in her normal state of good
health.
Past medical history is remarkable for obesity, which the patient attributes
to hypothyroidism. She has been menopausal for eight years. Specifically,
she has never had similar symptoms to those that prompted this presentation,
and she has no history of DVT, pulmonary embolism, or clotting disorders.
Past surgical history is significant only for liposuction three years
ago. Current medications include estrogen, thyroid supplement, and multivitamins.
Family history is positive for diabetes and coronary artery disease. Social
history is positive for a 40-pack-year cigarette smoking history, but
she stopped smoking two years ago. She works as a secretary in a legal
office. Review of systems is negative for constitutional symptoms such
as fever or appetite changes, for respiratory problems, for chest pain,
or for any bleeding problems. She has no known allergies.
Physical examination reveals an obese female who appears somewhat older
than her stated age. She is in no apparent distress. Vital signs are blood
pressure 152/88, pulse 88, respiration 20/min, and temperature 37.1°C
(98.8°F). She is 61 in (155 cm) tall and weighs 176 lb (80 kg). Pulse
oximetry reveals a room air oxygen saturation of 96%. The neck examination
reveals no jugular venous distention and no carotid bruits. Her heart
sounds are normal and there is no murmur, gallop, or rub. Respirations
are unlabored and the lungs are clear to auscultation. Her abdomen is
obese but soft and nontender. No organomegaly or masses can be appreciated.
Pulses are 2+ at the femorals; they cannot be palpated in the popliteal
fossa, but are 1-2+ and equal at the feet. The feet are warm and seem
well perfused. There is significant obesity of both legs but the patient
points out that her right leg appears to be swollen; this is difficult
to appreciate on inspection, but measured leg circumference is indeed
3 cm larger on the left than the right at mid-calf, and 2.5 cm larger
at the mid-thigh. There is no erythema and no cord is palpable. There
are noticeable varicosities on both lower extremities.
