Opening Scenario Riva George, a 35-year-old female, comes to the hospital complaining of pain in her

right calf.

Vital Signs.

BP: 130/70 mm.

Hg Temp: 99.9°F (37.7°C).

RR: 13/minute.

HR: 88/minute.

□ Chief complaint. “What brings you in today? Pain in my right calf muscle.

□ Onset. When did the pain begin? The pain started a few days ago and has gotten worse.

□ Frequency. Is the pain constant or does it come and go? It is present all the time.

□ Progression. Has the pain been of the same intensity the entire time?” The pain was mild in the
beginning, but now it hurts even when I take just a single step.

□ Severity on a scale. On a scale of 0 to 10, with 10 being the absolute worst pain of your life, and 0 being
no pain, how would you rate your pain now?” 8/10.

□ Radiation. Does the pain radiate or move anywhere?” No.

□ Quality. What does the pain feel like?” Pressure, spasms.

□ Alleviating factors. Does anything help to ease the pain?” Pain medication (ibuprofen). It also helps if I
prop up my leg with a pillow.

□ Exacerbating factors. Does anything make the pain worse?” Walking and extending my knee.

□ Swelling. Have you noticed any swelling? At the end of the day, my legs feel heavy and pit on pressure.

□ Injury. Have you experienced any recent injuries to the area?” Yes, I fell down and scratched my right
leg (points to bandage).

□ Redness. “Is there any redness?” Yes.

□ Warmth. “Is the area warm?” My right leg feels warmer than my left.

□ Varicose veins. Do you have any veins that are bulging and are visible through the skin on your legs?”
No.

□ Shortness of breath. “Have you had any shortness of breath?” No.

□ Chest pain. Have you had any chest pain?” No.

□ Recent immobilization. “Have you been immobile for an extended period of time recently; for example,
while traveling long distances or on bed rest?” I travel frequently as part of my consulting business, and a
week ago I took a 15-hour flight to meet an important client.
□ Fever. Have you had a fever recently?” I have felt warm recently but haven’t measured my temperature.

□ Last menstrual period. “When was your last menstrual period?” Two weeks ago.

□ Contraceptives. “Do you take contraceptive medication?” I have been taking oral contraceptives for 2
years.

□ Frequency of menstrual periods. “What are your menstrual periods like? Are they regular? How long
do they last? How heavy are they? Are they particularly painful?” Regular? My periods last 3 days, and I
use three to four pads. They are not accompanied by pain.

□ Obstetric history. “How many pregnancies have you had? Have you had any miscarriages? How many
children do you have? Any complications with any of your deliveries?” I have been pregnant twice and
have two kids. I haven’t had any miscarriages. Both times I had a normal vaginal delivery without
complications.

□ Last Pap smear. “When was your last Pap smear? What were the results?” One year ago; it was normal.

□ Weight changes. “Have you noticed any changes in your weight?” I gained 50 pounds after having my
last child 3 years ago.

□ Past medical history. “Do you have any medical conditions or health problems?” None.

□ Past surgical history. “Have you had any surgeries?” None.

□ Family history. “Any similar symptoms in your family? Any other diseases?” My dad had a clot in his leg.

□ Occupation. “What do you do for a living?” Executive consultant.

□ Alcohol use. “Do you drink alcohol?” No.

□ Illicit drug use. “Do you ever use recreational drugs?” No.

□ Tobacco. “Do you smoke cigarettes?” No.

□ Sexual activity. “Are you sexually active? With whom?” With my husband.

□ Drug allergies/herbal medication. “Do you have any allergies?” No.

Physical exam

Patient is a 35 yo F, married with two children.

Notes for the SP.

■ Exhibit pain in your calf when the doctor dorsiflexes your right ankle.

■ Place a bandage on your right leg to cover the cuts that you got after a fall.

Sample Closure.
Mrs. George, on the basis of your history and my physical examination, I believe it is possible that you had
a blood clot. However, we will also look for other possible causes of your symptoms, such as an infection
or a ruptured cyst. We will be running a few blood tests as well as some imaging studies that should help
us make a final diagnosis. If your test results show a clot, we will start you on blood thinners to prevent
further complications, such as the possibility of a clot traveling to your lungs. Do you have any questions
for me?

Challenging Questions to Ask.

My father had a clot in his leg. What do you think I should do to make sure I don’t get one too?”

Sample Examinee Response.

There are several measures you can take that may prevent you from having a clot. Above all, you should
avoid immobilization for long periods of time—for example, while sitting at your computer desk or on
long-distance plane trips. Try to move in place and perhaps take a short walk. If you are on oral
contraceptive pills, I strongly recommend that you stop taking them, as they are known to precipitate
clotting. Studies have also shown that obesity increases your risk of having a clot, so I suggest that you
exercise regularly and manage your diet.”