Author: Thomas Pommering, DO, FAMSSM
Co Author #1: Thomas L Pommering, DO, FAAFP, FAMSSM
Senior Editor: Mandeep Ghuman, MD, FAMSSM
Editor: Caitlyn Mooney, MD

Patient Presentation:
17 year old male high school hockey player was struck by a puck on the distal left medial tibia two weeks ago. He was able to keep playing but has since developed worsening medial distal tibial pain and localized medial ankle swelling. He has not had redness. The pain radiated into the medial foot down to the great toe. He was also very tender with a palpable cord in the same area that extended proximally. He has had no knee pain. His leg and ankle pain was getting worse and causing limping. He has had no chest pain, dyspnea on exertion, or shortness of breath.

History:
Past Medical History: Concussion.
Past Surgical History: Hernia repair.
Family Medical History: Thrombosis history:Mother was 51 years old and denied history of venous thromboembolism or miscarriages. Father was 53 years old and denied history of venous thromboembolism. Brother was 23 years old and had a recent history of video assisted thoroscopic surgery for a pneumothorax. Another brother was aged 22 years and healthy. Denied any family history of venous thromboembolism, recurrent miscarriages, early onset stroke or myocardial infarction.
Social History: 11th grader, honor roll student. Uses alcohol and marijuana.

Physical Exam:
Vital Signs: Temperature: 36.5C HR: 71 RR: 17 Height: 70.35 inches Weight: 64.8 kg Body Mass Index: 20.28
Gen: No acute distress, but has mild limp
Hydration: Well hydrated, Moist mucous membranes, good skin turgor
Chest: breath sounds clear and equal bilaterally, no respiratory distress
Cardiovascular: regular rate and rhythm, no murmur, brisk capillary refill
Abdomen: : soft, nontender and nondistended, no hepatosplenomegaly, no mass, normal bowel sounds
Neurologic Exam: alert, normal tone, no focal deficit
Left lower extremity: There was visible swelling and erythema over the medial ankle and arch. He had a painful, palpable cord extending from the medial ankle into the mid-calf. He had full range of motion of the knee and ankle. Homan’s sign was negative and no calf swelling was present. His calf circumferences were equal. There was no diffuse venous engorgement in the foot or LE.

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