Essay Elements:

• One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
• Brief introduction of the case
• Identification of the main diagnosis with supporting rationale
• Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
• Diagnostic plan with supporting rationale or references
• A specific treatment plan supported by recent clinical guidelines
  Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric:
  Aquifer Essay Outline

PATIENT DASHBOARD

PATIENT DASHBOARD

Patient Name: Mr. Harold Smith

• Age: 53
• Sex assigned at birth: male
• Gender identity: male
• Pronouns: he/him/his
• Language for medical communication: English

INTRODUCTION

You are working at a family medicine clinic with Dr. Hill. She tells you, “The next patient, Mr. Harold Smith, is a 53-year-old male with a chief concern of swelling and pain in his left lower extremity.”

Before you go to see Mr. Smith, a quick review of the chart reveals that he has type 2 diabetes, obesity, hypertension, and hyperlipidemia. You note that he has not been to the office in the past six months, and it appears that he should be out of all of his medications.

When you enter the examination room, Mr. Smith, a middle-aged male, greets you from where he is sitting. You introduce yourself and ask him what brings him to the office today.

He replies, “It’s my left leg. The past four days it has been red, swollen, and painful—and it seems to be getting worse.”

You ask him to tell you more about this problem.

He says, “It began several days ago, and the swelling seems to be getting worse. It hurts all the time; it doesn’t even get better when I rest it. It seems to get a little worse when I move around. It hurts to walk as soon as I try to stand on it.”

REASON FOR VISIT

After talking with Mr. Smith more, you discover:

Social History: Does not drink alcohol, but does smoke 1.5 packs of cigarettes daily, he is unmarried, and lives in public housing with his three children and one grandchild.

Family History: Father has hypertension. Mother has hypertension, diabetes, and history of a blood clot in her leg.

Review of Systems: No fever or chills, no chest pain, no shortness of breath, and no swelling of the right leg.

PHYSICAL EXAM 1

You examine Mr. Smith and find:

Vital Signs:

• Temperature is 36.5 C (97.8 F)
• Heart Rate is 85 beats/minute
• Respiratory Rate 12 breaths/minute
• Blood Pressure is 140/90 mmHg
• O2 Saturation is 98%

Cardiovascular and lung exam: Unremarkable

Lower extremity exam:

Mr. Smith’s entire left leg is swollen, warm, and erythematous. The measurement of the circumference of the largest left calf section is 3.5 cm larger than his right calf at the same location.

There is pitting edema. The leg is tender to the touch, especially along the distribution of the deep venous system.

Dorsalis pedis and posterior tibialis pulses are palpable on both feet. Digital capillary refill time is two seconds. Deep tendon reflexes are present (2+).

He has decreased sensation and is unable to determine the location of a monofilament test on either foot up to the ankle in a stocking distribution.

You note a 2 cm ulceration on the plantar surface of Mr. Smith’s left foot.

At this point, you excuse yourself to discuss your findings with Dr. Hill, assuring Mr. Smith you will return in a few moments.

SUMMARY STATEMENT

Mr. Smith is a 53-year-old male with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use who presents with a four-day history of left lower extremity edema. He reports no fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity. On exam he is afebrile. The entire left leg is swollen and erythematous, and his left calf is 3.5 cm larger in circumference than his right. There is an ulcer on the plantar surface of his left foot.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 53-year-old male with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use
2. Key clinical findings about the present illness using qualifying adjectives and descriptive language:

• Four-day history
• Unilateral
• No fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity
• Afebrile
• Left Leg circumference 3.5 cm greater than right
• Edema and erythema involving the entire leg
• Associated plantar ulcer

DIFFERENTIAL DIAGNOSIS

• A. Cellulitis
• B. Deep venous thrombosis
• C. Lymphedema
• E. Peripheral artery disease
• G. Venous insufficiency

DIAGNOSTIC TESTS 1 – E. Venous Doppler of the lower extremity

Dr. Hill praises you, “Very nice clinical reasoning. It looks as though you have correctly narrowed your differential down to two primary diagnoses: cellulitis and deep venous thrombosis (DVT). It is important to make sure when crafting a differential for unilateral lower extremity swelling that DVT is always on that list as it’s a condition that can lead to death if missed. Let’s consider what type of information would be most helpful to obtain next.”

DIAGNOSTIC CRITERIA – High probability

Wells Criteria for the Diagnosis of DVT

Active cancer (treatment ongoing or within previous six months or palliative)	1
Paralysis, paresis, or recent plaster immobilization of the legs	1
Recently bedridden for more than three days or major surgery within four weeks	1
Localized tenderness along the distribution of the deep venous system	1
Entire leg swollen	1
Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity)	1
Pitting edema (greater in the symptomatic leg)	1
Collateral superficial veins (non-varicose)	1
Previously documented DVT	1
Alternative diagnosis as likely or more likely than that of deep vein thrombosis	-2

Low probability 0 or less, moderate probability 1–2, high probability 3 or more.

DIAGNOSTIC TESTS 2

You conclude, “Given Mr. Smith’s high pretest probability of DVT, I don’t think I would trust a negative D-dimer result even with its high sensitivity. I think we have to get Mr. Smith a Doppler ultrasound instead.”

Dr. Hill agrees. “Ultrasonography is recommended as the initial test in a patient with high pretest probability.” And adds, “are there other diagnostic studies that you would order now?”

C. Complete blood count

E. Electrolytes, glucose, creatinine, and blood urea nitrogen (BUN)

F. Hemoglobin A1C

PHYSICAL EXAM 2 – B. Grade 2

You and Dr. Hill return to Mr. Smith’s room together. After greeting him, Dr. Hill explains, “Mr. Smith, we have a good idea of what may be causing the issues with your leg. We would like to gather some more information by taking a blood sample and sending you over to radiology for a Doppler ultrasound so that we can determine the best course of treatment for you.”

After Mr. Smith assents to the plan, Dr. Hill washes her hands and asks to take a look at his leg. She agrees with your assessment.

She walks you through a diabetic foot examination:

On Mr. Smith’s exam, Dr. Hill finds 3 out of 10 sites imperceptible using the 10-gram monofilament test, indicating some loss of protective sensation.

She finds Mr. Smith’s dorsalis pedis and posterior tibialis pulses intact bilaterally.

She notes a 2 cm ulcer on the plantar surface of his foot, with some surrounding erythema, and callous formation. The ulcer is deep, including full skin thickness, down to muscles and ligaments, but no exposed tendons, or bony involvement, and there appears to be no abscess formation.

She finds that the skin on Mr. Smith’s feet is dry and his toenails are dystrophic and incurvated, demonstrating inappropriate self-care.

At the end of the diabetic foot exam, Dr. Hill turns to you and asks, “What do you think we should do about his foot ulcer?”

You admit, “I’m not sure about that. Would antibiotics help?”

“They would if his wound is infected, but first we should evaluate the grade of the ulcer,” Dr. Hill explains.

REVIEWING LAB RESULTS – Uncontrolled diabetes

You and Dr. Hill determine that Mr. Smith’s foot ulcer does not require antibiotics at this time, but does require debridement, which you will address after he’s had his tests done. Mr. Smith has his blood drawn and a Doppler ultrasound performed.

A few hours later, you see that the results of the labs have returned:

Complete Blood Count:

Lab Value	Conventional	SI
WBC	7.5 x103/μL	7.5 x109/L
Hgb	13.7 g/dL	137 g/L
Hemoglobin A1C	10.2 %	.102

Chemistry:

Lab Value	Conventional	SI
Na	137 mEq/L	137 mmol/L
K	4.0 mEq/L	4.0 mmol/L
Cl	98 mEq/L	98 mmol/L
C02	25 mEq/L	25 mmol/L
BUN	18 mg/dL	6.3 mmol/L
Creatinine	1.0 mg/dL	88 mmol/L
Glucose	232 mg/dL	12.7 mmol/L

FORMULATING A PLAN

Dr. Hill informs you, “I just received a call from the radiologist. It looks as if our suspicions were correct. Doppler ultrasound shows that Mr. Smith has a DVT in the femoral vein. So now the question is: What do we do about it?”

You respond, “Well he needs anticoagulation to prevent a pulmonary embolus (PE), right?”

“Right. His short-term risk of a PE is high, so we need to anticoagulate him right away.”

DISCUSSION OF TREATMENT

Dr. Hill calls Mr. Smith’s pharmacy and finds that his insurance will only cover dabigatran and does not cover any other DOAC. Unfortunately, insurance does not cover the necessary pre-treament parenteral agent enoxaparin (injectable low molecular weight heparin) without prior approval, which may take a few days to achieve. (It is late in the day when you are seeing him.) Dr. Hill asks you if you think he would be better managed in the hospital or as an outpatient.

After thinking about it for a minute you respond, “I don’t think it is acceptable to send him home if we can’t ensure that he will be able to get enoxaparin or one of the DOACs that can be used for monotherapy tonight. His day-to-day risk of a pulmonary embolus is too high. Also, I am worried about his ability to adhere to new complicated instructions, given that he has a busy home and work life and has not been able to prioritize his own care. He needs to have a plan for managing his medications and he has this foot ulcer that needs care. I think it would be best to stabilize him in the hospital and work on having a more supportive home environment.”

Dr. Hill replies, “Excellent. I agree that Mr. Smith will be best treated in the hospital. Let’s look into how we will do that.”

IMPLEMENTATION OF TREATMENT PLAN

You and Dr. Hill decide to have Mr. Smith anticoagulated on LMWH because it doesn’t require laboratory testing and dosage titration and Mr. Smith may be more comfortable if he’s not hooked up to an IV.

Dr. Hill adds, “We only want to use low molecular weight heparin for a short term. After five days we will start dabigatran since he will need a longer course of anticoagulant therapy to reduce his risk of PE. In his case, his risk factors are not readily reversible, which will factor into our thinking about the duration of his treatment. If, for example, he had developed his DVT as a complication of surgery (a common and transient risk factor), we would have less cause for concern about his risk for recurrence of his DVT.”

SCIENCES EXCELLENCE IN ACTION

Dr. Hill asks you if the patient should get a thrombophilia workup, keeping in mind that these workups can be costly.

Having just had a session on value-based care, you respond that since this was the patient’s first thrombosis, you didn’t feel it would be cost-effective to do a thrombophilia workup.

However, Dr. Hill tells you, “We actually got lucky we caught Mr. Smith’s DVT when we did. It could have been worse. I am worried he may have an underlying predisposition to forming clots because of his mother’s history of a DVT and am worried about recurrence.”

MULTIDISCIPLINARY CARE

Dr. Hill says, “Since we are planning on treating Mr. Smith in the hospital, one of the advantages of inpatient treatment is that we can get the wound team nurse to evaluate his ulcer and make some recommendations. While we have Mr. Smith in the hospital, are there other specialists or team members that we can involve to improve his health?”

You suggest, “What about an endocrinologist to help with diabetes management?”

“Now there’s an interesting thought. What do you think is complicating Mr. Smith’s glucose control?”

You contemplate this, “In thinking about his history, it seems that he has been nonadherent with his medication regimen, diet, exercise program, and his follow-up appointments for some time. He describes a stressful social situation at home with family and financial problems, as well as work-related stress.”

“How do you think an endocrinology consult will help with that?” Dr. Hill wants to know.

“I see your point,” you admit. “His problems in managing his chronic illness seem to be more social than medical.”

“That’s right.” Dr. Hill adds, “It’s possible that an endocrinology consult might be useful down the road, especially if he is brittle or otherwise difficult to control on routine medication, but we really have not had the opportunity to see if standard care will be successful because of his social factors.”

“So, I guess it might be better if we get some recommendations from a diabetes educator, a social worker and maybe even the Pharm D,” you suggest.

“Excellent! Ideally, we could all meet in a room and map out a plan for his care, but this isn’t practical in reality. Instead, our role, as the family clinician, is to assume responsibility for coordinating and directing his care and ensuring that everyone on the team is working toward the same goal.” Dr. Hill explains.

DISCUSSING THE PLAN WITH THE PATIENT

Several days have gone by and you and Dr. Hill are now rounding on your patients in the hospital. When you get to Mr. Smith, you tell Dr. Hill:

“This is Mr. Smith’s third day in the hospital. He says he is feeling better, the pain and swelling in his leg is improving. His temperature is 36.2 C (97.2 F), his pulse is 80 beats per minute, his respiratory rate is 16 breaths per minute, his blood pressure is 128/78 mmHg. On exam, his foot ulcer has some fresh granulation tissue on the wound edges. Labs include his fasting glucose this morning was 128 mg/dL (7.0 mmol/L). His CBC was normal and his platelets are stable from admission.”

Dr. Hill responds, “Good. I just got word from his pharmacy that the enoxaparin has now been approved by his insurance, so if he can inject himself for two more days, he can go home. We will need to arrange a close follow-up with visiting nurses and at our office, so he can continue his treatment for his diabetic foot ulcer.”

You comment, “This all seems so much easier than it would have been if he were taking warfarin. How long would it take to get his INR to the therapeutic range if he were using warfarin?”

Dr. Hill tells you, “It varies a lot from person to person, but it commonly takes at least five days for a patient’s INR to get above 2.0. When starting it, you have to balance speed with the risk of overshooting his INR goal and ending up increasing his risk of bleeding by making him supratherapeutic. It is good to consider warfarin dosing since it is still commonly used. It is a very effective medication, but it can be dangerous as well.”

FOLLOW-UP 2

“What do you think we should do next?” Dr. Hill wants to know.

After contemplating this for a moment, you conclude, “Since his insurance has now approved the prior authorization for 2 days of enoxaparin he can finish the pretreatment phase at home. He has been on enoxaparin for three days now. My understanding is that he needs to be on enoxaparin for 5 days and then he can begin the dabigatran. He will need to be able to give himself the enoxaparin at home for 2 days and then be able to start the oral dabigatran about 12 hours after his last dose of enoxaparin. His floor nurse has been showing him how to give the injections, so I think he will be able to do it. He said he doesn’t like it very much, but he would do it if he has to.”

You continue, “He’s back on his regular medications which have improved his blood pressure and glucose. The foot ulcer has been debrided and is getting better. There doesn’t seem to be much more for us to do in the hospital, so I think he might be ready to go home later today.”

“I agree,” Dr. Hill replies. “What type of arrangements will he need at home?”

“Home health should be able to manage his wound. I would think with that and close follow-up in the office, he should do well,” you predict. “We also need to make sure he understands the timing of the enoxaparin and transition over to the dabigatran, and that he knows where to pick up both his medications.

You also remind Dr. Hill that Mr. Smith’s obesity and smoking still pose tremendous risks to his health and that in future visits to the clinic, he should be counseled regarding weight loss and smoking cessation as well as managed for hypertension, hyperlipidemia, and diabetes.