Mrs. Leahy's Case Summary

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CC Mrs. Leahy is a 72-year-old female here today with complaints of right leg pain. HPI The patient tells me this has been ongoing now for the last two months. There was no specific injury or trauma. She was describing a pain and ache in her right leg. She said she was not paying much attention to exactly where it was and elected to go see urgent care on September 3th. I do have that note from the physician that she saw there. At that time, her main complaint was right knee pain. She had x-rays done that showed some mild osteoarthritis and she is here today to follow up on that. She says after that visit, she really started trying to pay attention to where the pain was coming from and she realized it is really coming throughout the whole leg, particularly the thigh area, the knee, down the back of the leg as well, and she also feels it a little into the right buttock. No injury or trauma. There is no real low back pain associated with this. No weakness that she has noticed. No numbness or tingling that she has had. She is having no other joint issues that she can recall. She is not having fevers. There has been no redness or swelling. She is overall feeling okay. She is a little bit more tired than typical. No associated fevers, chills, or other body …show more content…

No pain with pelvic rock. She has full flexion and extension at the bilateral hips. It seemed equal. She has full flexion and extension at the knee and otherwise normal. No redness. No swelling. No pain directly over palpation of the femur, the tibia or fibular area. No obvious swelling or tenderness directly in the calf. She points essentially all over her lower leg as to where she is having pain, and is finding it difficult to identify a specific area. She is somewhat tender in the right buttock is well. There are venous changes noted on her bilateral lower extremities with multiple varicosities, but an otherwise essentially normal

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