Case Analysis Tool Worksheet
Student’s Name:
- Epidemiology/Patient Profile
| Mr. Smith is a 53-year-old Caucasian male who presented to the clinic complaining of swelling and pain in his left lower extremity. Medical history of obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use. He appears to be a good historian. |
- Prioritized Cues from Hx and PE.(Do not include lab, x-‐ray, or other diagnostic test results here.)
- Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
- Tier 2: These are cues of intermediate importance (list only positive cues).
- Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3
| Swelling and pain in his left lower extremity for 4 days | Denies of fever, chest pain, shortness of breath. | Staying in public housing with family |
| Pain worsen with weight bearing and movement | Dorsalis pedis 2+ | |
| Neuropathy of lower extremity | Posterior tibial pulses are palpable bilaterally | |
| Left foot plantar surface ulceration noted. | ||
| Left calf circumference is larger than right by 3.5 cm | ||
| Smoker 1.5 packs/day | ||
| Medical history of obesity, type 2 diabetes, hypertension, hyperlipidemia | ||
| Left leg Erythematous and edematous | ||
| Tenderness of the left leg along the distribution of deep venous system. |
III. Problem Statement
| Mr. Smith is a 53-year-old Caucasian male who presented to the clinic complaining of 4 days worsening swelling and pain in his left lower extremity. The patient reports pain not relieved by rest and aggravated with standing up or movement. Swollen and erythematous of bilateral lower extremities, and left calf circumference is larger than right by 3.5 cm. Left foot plantar surface ulceration noted. Medical history of obesity, type 2 diabetes, hypertension, hyperlipidemia, and 1.5 packs tobacco use a day. He appears to be a good historian. |
- Differential Diagnosis
Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s).
List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.
Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.
| Deep Vein Thrombosis (I82.492) |
History Finding(s) Physical Exam Finding(s)
| Swelling and pain in his left lower extremity for 4 days. | Tenderness of the left leg along the distribution of deep venous system. |
| Pain worsen with weight bearing and movement | Left calf circumference is larger than right by 3.5 cm |
| Smoker 1.5 packs/day | Left leg Erythematous and edematous |
(Stone et al., 2017)
Alternative dx:
| Cellulitis of left lower limb (L03.116) |
History Finding(s) Physical Exam Finding(s)
| Swelling and pain in his left lower extremity for 4 days. | Tenderness of the left leg along the distribution of deep venous system. |
| Pain worsen with weight bearing and movement | Left calf circumference is larger than right by 3.5 cm |
| Left leg Erythematous and edematous | |
(Brown & Hood Watson, 2021)
Alternative dx:
| Venous insufficiency (I87.2) |
History Finding(s) Physical Exam Finding(s)
| Swelling and pain in his left lower extremity for 4 days. | Tenderness of the left leg along the distribution of deep venous system. |
| Pain worsen with weight bearing and movement | Left calf circumference is larger than right by 3.5 cm |
| Smoker 1.5 packs/day | Left leg Erythematous and edematous |
| PMH: Diabetes | Left foot plantar surface ulceration noted. |
(Patel & Surowiec, 2020)
- Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
| Complete Blood Count | This test gives helpful information about the patient’s overall health, including anemia and infection, both of which can be important in ruling out a diagnosis of cellulitis (Cash & Glass). |
| D-Dimer Test | D-dimer test is best used to rule out a DVT if the pretest probability of having a DVT is relatively low. |
| Venous Doppler Ultrasound | It has the ability to properly assess the size, chronicity, and degree of blockage of a thrombus, and as a result, it can better guide the choice as to whether medical care or interventional procedures should be pursued (Stone et al., 2017). |
Treatment Plan Rationale
| Counsel to stop smoking. | The more frequently a person smokes, the greater their risk of developing a deep vein thrombosis (DVT) (McLendon & Attia, 2020). |
| Discuss anticoagulation therapy. | If the patient tests positive for DVT, the patient should be informed about the various anticoagulant choices as well as the possible long-term therapy (Stone et al., 2017). |
| Follow-up in 1 to 2 days | Instruct the patient to follow 1 to 2 days when results of laboratory and diagnostic testing is available to determine the appropriate course of treatment. |
| Advised to go to the Emergency Department if symptoms worsen. | Patients who are considered to be at high risk or who have other medical conditions and have positive findings of DVT need to be admitted to the hospital for further testing and evaluation (Wilbur & Shian, 2017). The patient is to be treated for both wound care and diabetic management and control once they are discharged from the hospital. The wound care treatment will be followed up in primary care. |
