Comprehensive DVT (Deep Vein Thrombosis) Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: Sarah Anne Thompson
Date of Birth: 08/14/1984
Age: 40
Gender: Female
Medical Record Number: 20250314
Date of Admission: 03/14/2025
Primary Care Provider: Dr. James Carter

Chief Complaint (CC)

"My right leg has been swollen, painful, and warm for the last couple of days. It started in the calf and has gotten worse."

History of Present Illness (HPI)

Sarah Thompson is a 40-year-old female who presents with a complaint of progressively worsening pain, swelling, and warmth in her right lower leg, which began 3 days ago. She first noticed mild calf discomfort and swelling, which has progressively worsened. She reports that the pain has become sharp and more pronounced, especially when walking or standing for prolonged periods. The affected leg is also warm to the touch, and she describes the swelling as more noticeable in the calf and ankle areas.

The patient denies any recent trauma, but she does note that she has recently traveled on a long flight from New York to California, which may have contributed to her symptoms. She also has a family history of blood clots and was recently diagnosed with oral contraceptive use.

Past Medical History (PMH)

• Oral Contraceptive Use – diagnosed 5 years ago, currently using birth control pills
• Obesity – BMI of 32 (overweight)
• Asthma – diagnosed in childhood, managed with Albuterol inhaler as needed
• Hyperlipidemia – diagnosed 3 years ago, controlled with Atorvastatin
• No known history of clotting disorders.

Surgeries & Procedures

• Appendectomy (20 years ago)
• Laparoscopic gallbladder removal (10 years ago)

Allergies

• Penicillin – Rash

Medications

• Levonorgestrel/ethinyl estradiol (Oral contraceptive) daily
• Atorvastatin 20 mg daily
• Albuterol inhaler as needed for asthma
• Multivitamin daily

Family History (FH)

• Father: Alive, 65, with a history of hypertension and hyperlipidemia
• Mother: Alive, 63, with a history of breast cancer and obesity
• Brother: Alive, 38, healthy with no significant medical history
• Maternal Grandfather: Died of a pulmonary embolism at age 72

Social History (SH)

• Smoking: Non-smoker
• Alcohol: Occasional drinker (1-2 drinks per week)
• Drug Use: Denies illicit drug use
• Occupation: Administrative assistant (sedentary lifestyle)
• Living Situation: Lives with husband and two children, independent in activities of daily living

Review of Systems (ROS)

• General: No fever, chills, or weight loss
• Cardiovascular: No chest pain, palpitations, or dizziness
• Respiratory: No shortness of breath or cough
• Gastrointestinal: No nausea or vomiting
• Musculoskeletal: Right calf pain, swelling, and warmth
• Neurological: No numbness or tingling, no headaches or visual changes

Physical Assessment Findings

Vital Signs:

• Temperature: 98.7°F (37.1°C)
• Heart Rate: 85 bpm, regular
• Respiratory Rate: 16 breaths/min
• Blood Pressure: 120/78 mmHg
• Oxygen Saturation: 98% on room air
• Height: 6'0"
• Weight: 160 lbs. General Appearance: Overweight female, alert, in mild distress due to pain
  Cardiovascular: No jugular venous distention, no cyanosis
  Respiratory: Clear to auscultation bilaterally, no wheezing or crackles
  Musculoskeletal: Right leg is swollen, tender to palpation, warm to the touch, positive for Homan's sign (pain with dorsiflexion of the foot), no redness noted
  Neurological: Alert and oriented, no focal deficits

Laboratory Results

Basic Metabolic Panel (BMP)

Complete Blood Count (CBC)

Coagulation Studies

Duplex Ultrasound of Right Leg

Findings:

• Extensive thrombus noted in the right popliteal vein extending into the calf veins, consistent with deep vein thrombosis (DVT). No evidence of thrombus in the femoral vein.
• No signs of superficial thrombophlebitis.