Leg Pain and Swelling

33 year old male presents to the ED complaining of leg pain and swelling.  He states he had what he thought was an insect bit on his lower leg, near his ankle. "It was a painful bump on my ankle." He tried to pop it without much coming out.  Over the next couple days his ankle and lower leg became erythematous and swollen.  He now complains of generalized pain of that lower extremity.  Denies fever, headache, chills, nausea, or vomiting.

PMH: none
Allergies: Penicillins (rash)
Social History: non-contributory
Meds: daily vitamin

VS: HR82, RR18, BP138/70, O2 99% on RA, T 99.2

Labs:
CBC: Hb 12.5, Hct 39, WBC 12.5, Plt 200,000
CMP: Na 125, K 4, Cl 109, CO2 25, BUN 8, Cr 0.8, Glu 109

PE: Alert, oriented, and pleasant 33 y/o M in no acute distress. Normal S1S2 w/o MRG, lungs CTAB, abdomen S/NT/ND, peripheral pulses 2+ bilaterally (radial, DP, PT).  R lower extremity has some distal erythema, edema, and is warm and tender to the touch.  Small (<1cm) papule on R ankle without drainage. Distal sensation and ROM intact.

(His leg looks similar to this)

1. What is your differential diagnosis (list at least 3)?

2. What is your plan (include your patient disposition)?

3. What kind of patient education would you provide and what is your plan for follow up care (these are very important for your patient and your documentation)?

29 year old with hyperglycemia

29 year old female presents abdominal pain, nausea, vomiting, and confusion.  Patient stated her nausea and abdominal discomfort began a few days ago and has progressively gotten worse.  She states she is a diabetic and her sugars have been running high.  She explains she was supposed to switch insulin regimens a week ago, but had some issues at the pharmacy and has continued on her previous regimen until those issues are resolved.  She was diagnosed with diabetes 5 years ago following her first pregnancy in which she had gestational diabetes.

Weight: 80kg

PMH: Diabetes
Allergies: NKDA
Meds: 20 units NPH qd, NovoLog 13 units with meals, Prenatal Vitamin

VS: BP 110/70, HR 106, T99, RR16

PE:
CV: normal S1, S2, no MRG, 2+ peripheral pulses, no cyanois, cap refill < 2 secs
Pulm: lungs CTAB, normal work of breathing
Abdomen: soft, non-distended, mild tenderness to palpation, bowel sounds normative x 4
Neuro: mild confusion, appropriate deep tendon reflexes, cranial nerves intact
Skin: supple, moist, no rashes, ulcers, or lesions
HEENT: normocephalic atraumatic, nasal mucosa moist, nares patent, oropharynx pink and moist without erythema or exudate, trachea midline, no lymphadenopathy

Labs:
Hb: 12
Hct: 38
WBC: 14
Plt: 152

Na: 140
K: 3.5
Cl: 100
CO2: 28
BUN: 18
Cr: 0.9
Glu: 442
Serum Osm: 330

UA: negative (no WBC, no RBC, no Ketones, etc.)
Urine HCG: negative

Tests / Imaging:
KUB: no acute findings
CXR: no acute findings
EKG: sinus tachycardia


1. What is your differential diagnosis? (Will list some follow up questions about making a plan)

Forum Test

This is a test post to see if having a discussion about clinical questions would work in this format.  If you wouldn't mind, answer the following question below.  Hopefully we will have more detailed and challenging cases in the future.

What is the preferred antihypertensive of choice for a 45 year old African American with a BP that is consistently 148 / 92?