Site Evaluator: Fahim Sadat, PA-C

For my site visit, the H&P I presented was of a 71 year old female who had come into the office complaining of a swelling in her right lower leg that started 4 days ago. She had a past medication history of HTN and HLD and a 20-pack smoking history. The patient had reported a constant, dull achy pain in the area, aggravated when she walked. She also said that the area look a little more red than the left side and felt warm. A key piece of information she noted was that she had come back from a trip to Rome a week prior to symptom onset where she did a considerable amount of walking and standing. The physical exam was consistent with the patient’s report of mild swelling of the right lower extremity with tenderness to palpation especially to the lateral and posterior aspects. The skin as warm to touch and mildly erythematous. No ulcers or traumatic injury were noted, negative Homan sign, and no pitting edema. An ABI was able to be done in office, which showed 1.13 brachial index of both the left and right ankle, ruling out peripheral artery disease. A STAT venous duplex ultrasound was ordered to rule out DVT vs superficial phlebitis/thrombophlebitis. There was low suspicion for pulmonary embolism at the time due to the patient’s stable vitals and absence of cough, sudden shortness of breath, chest pain, dizziness, or heart palpitations. Pending results, the patient was advised to use compression stockings, apply warm compresses to the area, and keep the legs elevated when she is sitting. If the results came back positive for DVT, the patient was told that she would need to be started on an anticoagulant immediately. I chose this case because I was given the opportunity to act in a primary role. Mr. Sadat agreed with my assessment and plan. It prompted a discussion on when a d-dimer would be ordered and red flag signs that would raise suspicion for a pulmonary embolism.  

The other H&P that I had written up was a 85 year old male who had presented to the office complaining of painless right eye redness that started a day ago. Given the patient’s medical history of HTN, HLD, DM2, atrial fibrillation, and CHF, and the absence of any visual disturbances or other irritative symptoms, the most suggestive diagnosis is spontaneous subconjunctival hemorrhage. Due to the patient being asymptomatic and no history of trauma, there is very low concern for corneal ulcer or other conjunctival injuries that require emergent ophthalmology care.  Treatment was symptomatic.