Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case Family Medicine 07 53-year-old male with leg swelling.

Sample Answer

Week 6 Discussion

DOMAIN HISTORY

Identify two (2) additional questions that were not asked in the case study and should have been?

• Have you experienced sudden -onset shortness of breathe?
  
• Have you experienced chest pain or coughed blood?

Explain your rationale for asking these two additional questions.
Shortness of breath, chest pain, coughing blood (hemoptysis) can point to presence of a dislodged clot in the lungs, which occurs in pulmonary embolism (PE) (Nicholson et al., 2020).

Describe what the two (2) additional questions might reveal about the patient’s health.

The above questions may reveal if the patient has Venous thromboembolism (VTE), which includes both thrombus and embolus complications (Devi et al., 2021).

DOMAIN PHYSICAL EXAM

For each system examined in this case;

Explain the reason the provider examined each system.
Lower extremity The provider examined the lower extremity to assess for possible deep venous thrombosis (DVT) findings including erythema, edema, Distended peripheral veins, varicose veins, and ulcers. These usually indicate venous insufficiency, which is a primary risk factor for DVT.

Cardiovascular and lung exam A cardiovascular and neck exam was performed to assess for signs of PE. Many patients usually have silent PE by the time symptomatic DVT is diagnosed.

Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.

Abnormal exam findings in the Lower extremity would include tenderness on palpation, swelling of the whole leg, more than 3 cm difference in circumference between calves, pitting edema, and collateral superficial veins (Nicholson et al., 2020). In addition, the patient may have a positive Homans sign, which is calf pain on dorsiflexion of the foot with the knee straight.

Abnormal findings on Cardiovascular and lung exam would include Rales, Accentuated second heart sound, Tachycardia, S3 or S4 gallop, and Cardiac murmur (Devi et al., 2021).

Describe the normal findings for each system.
Normal findings in the lower extremity include Skin color consistent from upper legs to toes; Equal limb circumference with no edema or ulcers; No of cyanosis or pallor on nails; Capillary refill within 2 secs; Dorsalis pedis and posterior tibial pulses 2+ force and equal bilaterally.

Normal findings in the Cardiovascular and lung exam include Symmetric thorax; antero- posterior transverse diameter is 1 2; no retraction of intercostal space during inspiration; respirations are regular and even in rhythm, inspiration is non-exaggerated and effortless; The thorax rise and fall in unison (Dearnley-Lane, 2020).

Lungs are clear on auscultation with no wheeze, rales, rhonchi, or crackles. In addition, Point of Maximum Impulse (PMI) is not visible and is palpable in the 5th intercostal space at the mid-clavicular line; Heart rate and rhythm are normal; No murmurs, gallops, or rubs on auscultation (Dearnley-Lane, 2020).

Identify the various diagnostic instruments you would need to use to examine this patient.
The diagnostic instruments needed to examine the patient include a stethoscope for auscultation of lungs, heart, and peripheral pulses. A tape measure would be necessary to measure the diameter of the calf in the different limbs.

DOMAIN ASSESSMENT (Medical Diagnosis)

Discuss the pathophysiology of the

Diagnosis and, DVT is the diagnosis for this patient. Lower extremity DVT usually results from Impaired venous return such as in immobilized patients; Endothelial injury or dysfunction (after leg fractures); and Hypercoagulability (Obi et al., 2021). DVT often occurs due to thrombus complications. When a thrombus develops, inflammation occurs around the clot, resulting in thickening of the vein wall and possibly leading to embolization

Each Differential Diagnosis

The differential diagnoses are cellulitis and lymphedema
Cellulitis Cellulitis is a non-necrotizing inflammation of the skin and subcutaneous tissue from a primary infection. It is a generalized infection with either Staphylococcus or Streptococcus and involves the deeper connective tissue. It can occur due to a secondary bacterial infection of an open wound, or it may be unrelated to skin trauma.

The skin barrier is usually compromised. Streptococci cause diffuse, rapidly spreading infection because enzymes produced by the organism (streptokinase, DNase, hyaluronidase) break down cellular components that would otherwise contain and localize the inflammation (Rrapi et al., 2021). Staphylococcal cellulitis is typically more localized and occurs in open wounds or cutaneous abscesses.

Lymphedema Lymphedema is edema of a limb caused primarily by lymphatic hypoplasia or to obstruction or disruption (secondary) of lymphatic vessels. Brix et al. (2021) explain that imbalances in lymphatic fluid generation, transport, outflow, or dysfunctional vessels can cause lymphedema. It is a progressive disease that causes a massive accumulation of fluid. It usually occurs in the extremities and it is a disabling disease.

References

• Brix, B., Sery, O., Onorato, A., Ure, C., Roessler, A., & Goswami, N. (2021). Biology of Lymphedema. Biology, 10(4), 261. https //doi.org/10.3390/biology10040261
  Dearnley-Lane, J. (2020). Cardiovascular examination. Journal of Paramedic Practice, 12(4), 1-4. https //doi.org/10.12968/jpar.2020.12.4.1
  
• Devi, S., Mohakud, S., Kar, N., & Muthuvel, D. (2021). Deep vein thrombosis with pulmonary thromboembolism in a case of severe COVID-19 pneumonia. BMJ case reports, 14(1), e240932. https //doi.org/10.1136/bcr-2020-240932
  Nicholson, M., Chan, N., Bhagirath, V., & Ginsberg, J. (2020). Prevention of Venous Thromboembolism in 2020 and Beyond. Journal of clinical medicine, 9(8), 2467. https //doi.org/10.3390/jcm9082467
  
• Obi, A. T., Barnes, G. D., Napolitano, L. M., Henke, P. K., & Wakefield, T. W. (2021). Venous thrombosis epidemiology, pathophysiology, and anticoagulant therapies and trials in severe acute respiratory syndrome coronavirus 2 infection. Journal of vascular surgery. Venous and lymphatic disorders, 9(1), 23–35. https //doi.org/10.1016/j.jvsv.2020.08.030
  
• Rrapi, R., Chand, S., & Kroshinsky, D. (2021). Cellulitis A Review of Pathogenesis, Diagnosis, and Management. The Medical clinics of North America, 105(4), 723–735. https //doi.org/10.1016/j.mcna.2021.04.009