EM Forum Case #161 "Return Visit for Vicoden Refill"
by Charlene Babcock Irvin, MD, FACEP
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A 37 y/o male presents for a prescription refill. He was in the ED last week for vague leg pain, was given Vicoden for pain, and now returns for a refill of his pain medication as his leg is still hurting him. He denies any trauma, and notes the leg began to bother him about 10 days ago, and hasn’t improved. The pain is described all over, not worse in any one place, better with Vicoden, worse when he stands for too long. When he was in the ED, he had an x-ray and an ultrasound done. He doesn’t have any insurance, so he has not made a follow-up appointment.
PMH: Struck by a car 8 years ago and subsequent femur fracture with open repair.
Social history: Recovered alcoholic, lives in basement of friend's home, unemployed. Non-smoker
ROS: No fevers, chest pain, shortness of breath, abdominal pain, vomiting, bowel or bladder problems, rashes.
PE: Appears older than stated age. Rest of exam unremarkable except R. leg.
R.leg: Scar present lateral thigh, +1 pretibial pitting edema. Entire R. leg swollen compared to left (although patient notes leg is always swollen some after accident, he thinks the swelling is worse).
Pulses normal, normal capillary refill, R. calf 3 cm greater compared to L.leg.
Normal motor and sensory exam, no point boney tenderness. On palpation, diffuse tenderness to entire leg (not localized to venous system). ROM of leg normal. No significant swelling or edema noted on left leg.
Review of last ED visit: X-ray: no acute abnormality, hardware in femur unchanged.
Ultrasound of leg: No DVT.
Questions:
1.
What is his Wells score?
2. Does he need a repeat ultrasound?
3. What is the difference between heparin and a Low-Molecular-Weight Heparin (LMWH) like Enoxaparin?
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