Clinical Case Study

Calf pain

Background

Mr. Smith is a 71 year old male who has always been very fit and active. However, three weeks ago while on vacation, he suffered a calf injury. Upon seeking medical attention, he was told by the doctor that he had a calf tear and was given pain medication and instructed to rest.

Initially, the pain relief and rest seemed to help. However, upon returning to the UK, Mr. Smith noticed that the pain in his calf was getting worse. He began to experience difficulty walking and found it difficult to put any weight on his right leg.

Concerned about the worsening pain and mobility issues, Mr. Smith decided to seek out a second opinion.

Clinical presentation

Mr Smith attended the practice face-to-face. There was clear discomfort in his face due to pain, and mobilised into the room with an antalgic gait. He had no other past medical history.

Upon examination, the affected leg appeared to be red and swollen compared to the contralateral side. The calf itself felt hot, with pitting oedema present.

What next?

Mr Smith presented with symptoms suggestive of a lower limb Deep Vein Thrombosis (DVT). He was sent urgently for same day investigation. A DVT was identified and managed appropriately.

Take home points?