Diagnosis essay (4).edited.edited (1)

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Nov 24, 2024

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Case Analysis Name Institution Course Instructor Date

Case Analysis Introduction Mr. Smith is a 53-year-old Caucasian male who complains of pain and swelling in the left lower extremity. He has a history of tobacco use, hypertension , obesity, and hyperlipidemia The diagnosis for the patient is deep vein thrombosis. The presenting symptoms of swelling and pain in the left lower extremity for 4 days, pain worsening with weight bearing movement and smoking 1.5 packs of cigarettes per day supports the diagnosis (Waheed et al., 2022). Supporting physical assessment findings include; tenderness of the left leg along the distribution of deep venous system, left calf circumference larger than right by 3.5 centimeters and the left leg is erythematous and edematous (Waheed et al., 2022). Differential Diagnoses (must have two differentials) Differential 1 One of the differentials is cellulitis of left lower limb as evidenced by the presentation of swelling and pain of the left lower extremity for 4 days and pain that worsen with weight bearing or movement (Brown & Hood Watson, 2022) .The differential is further supported by physical exam findings of tenderness of the left leg along the distribution of deep venous system, left calf circumference larger than right by 3.5 centimeters and the left leg is erythematous and edematous (Brown & Hood Watson, 2022) .Cellulitis of the lower limb are less likely, however, due to a lack of manifestation of generalized malaise, a fevers and lymphadenopathy (Brown & Hood Watson, 2022). Differential 2 Venous insufficiency is another possible differential for the patient. The differential is evidenced by the patient's presenting symptoms of swelling and pain in the left lower extremity

for 4 days, pain worsening with weight bearing movement, smoking 1.5 packs of cigarettes per day and past medical history of diabetes (Azar et al., 2022) . The differential is supported by physical exam findings of tenderness of the left leg along the distribution of deep venous system, left calf circumference larger than right by 3.5 centimeters, the left leg is erythematous and edematous and presence of left foot planter ulceration (Azar et al., 2022). Venous insufficiency is less likely due to the absence of fatigue and venous stasis dermatitis (Azar et al., 2022). Diagnostics Diagnostics, including complete blood count, D-Dimer test and venous doppler ultrasound are essential in confirming deep vein thrombosis The complete blood count is vital for checking the levels of blood cells and therefore assessing the general overall health . D dimer test is essential for ruling out deep vein thrombosis. Venous doppler ultrasound is a ultrasound that monitors the flow of blood and therefore detect the presence of blockage of the blood vessels (Waheed et al., 2022). Treatment Plan Educating the patient to stop smoking is essential because smoking is related with increased risk of development of deep vein thrombosis. In cases where the patient tests positive for DVT, it is vital to discuss the various anticoagulation therapies including those for long term basis (Waheed et al., 2022). The patient should follow-up in one or two days for the diagnostic test results and determination of the appropriate course of treatment. In cases of positive findings of DVT , it is vital to refer the patient to emergency department for admission, further testing and wound acre and diabetes management.

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References Azar, J., Rao, A., & Oropallo, A. (2022). Chronic venous insufficiency: a comprehensive review of management. Journal of Wound Care , 31 (6), 510–519. https://doi.org/10.12968/jowc.2022.31.6.510 Brown, B. D., & Hood Watson, K. L. (2022, August 8). Cellulitis . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549770/ Waheed, S. M., Kudaravalli, P., & Hotwagner, D. T. (2022). Deep Vein Thrombosis . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507708/#:~:text=Deep %20Vein%20Thrombosis%20%28DVT%29%20-%20StatPearls%20-%20NCBI

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