Physician's Assistant

Patient Details

Sdec (283 days ago 16:17)

Sdec Fri 27 June 2025 16:17

Last Modified: 283 days ago

MRN:

Content:

Presenting Complaint:
Left leg swelling and pain

Past Medical History
• Left knee replacement 18 months ago
• Previous Achilles tendon rupture (opposite leg)

Diagnosis:
Suspected ruptured Baker's cyst vs Achilles tendon injury

I had the pleasure of meeting Mr William Ayers in Same Day Emergency Care today.

Mr Ayers is an 79-year-old retired lorry driver who presented with a 1-day history of left leg swelling and pain. The symptoms began as an ache in the lower leg yesterday, progressing to obvious swelling. The swelling extends from the ankle to the knee, with significant tenderness particularly around the achilles . He denies any trauma or precipitating event. Of note, he has a history of left knee replacement 18 months ago with good recovery, and previous Achilles tendon rupture on the contralateral side during weight training.

On examination, there was visible swelling of the left lower leg extending from ankle to knee level. The leg appeared slightly darker than the contralateral side but without erythema. Ankle dorsiflexion was extremely painful and limited, whilst plantarflexion was tolerable. The knee prosthesis appeared well positioned without swelling or warmth.

Social history reveals he lives with his wife, is a social smoker, and drinks alcohol occasionally. He has been using crutches for mobility.

Investigations:
Creatinine: 112 (previous 114 in May 2024)
Electrolytes: Normal
LFTs: Normal
D-dimer: 0.4 (negative)
FBC: Normal
Venous blood gas: Normal
ESR: 0
ECG: Right bundle branch block, left axis deviation, PR 208ms, first degree AV block. Repeated and PR 188ms, bifascicular block.

Plan:
1. Analgesia
2. Orthopaedic review for assessment of suspected achilles tendon pathology

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Sdec (283 days ago 16:26)

Sdec Fri 27 June 2025 16:26

Last Modified: 283 days ago

MRN:

Content:

Presenting Complaint:
Left leg swelling and pain

Past Medical History
• Total prosthetic knee replacement (April 2024)
• Partial seizure (December 2024) - right focal
• Acute non-ST segment elevation myocardial infarction (January 2022)
• Essential hypertension
• Carotid artery stenosis - right carotid endarterectomy and patch repair (April 2021)
• Transient ischaemic attack (March 2021)
• Mobitz type I Wenckebach atrioventricular block
• Chronic kidney disease stage 3
• Pre-diabetes
• Ruptured Achilles tendon - traumatic (June 2019)
• Gout
• Osteoarthritis
• Mild frailty
• Obesity (BMI 30+)

Diagnosis:
Suspected Achilles partial rupture with associated lower leg swelling

I had the pleasure of meeting Mr William Ayers in Same Day Emergency Care today.

Mr Ayers is an 79-year-old retired lorry driver who presented with a 24-hour history of left leg swelling and pain. The symptoms began as an ache in the lower leg yesterday and progressed to obvious swelling. The swelling extends from the ankle up to the knee, with the knee itself appearing normal. He reports significant tenderness particularly around the ankle area, with pain on dorsiflexion but less discomfort on plantarflexion.

Mr Ayers had a left total knee replacement approximately 18 months ago which went well. He has a significant past medical history including a previous traumatic Achilles tendon rupture (right side) in 2019, which he describes as feeling similar to his current symptoms, though he did not experience the characteristic 'snap' sensation with this episode. He also suffered a myocardial infarction in January 2022 and has had a right carotid endarterectomy.

On examination, the left leg shows obvious swelling below the knee extending to the ankle. The area is tender to palpation, particularly around the ankle. There is no obvious erythema or signs of infection. The swelling does not extend above the knee.

He lives with his wife and is independent. He describes himself as a social smoker and drinks alcohol occasionally but not regularly. Has been using crutches.

Investigations:
D-dimer: 0.4 (negative)
Creatinine: 112 (previous May 2024)
Electrolytes: normal
LFTs: normal
FBC: normal
Venous blood gas: normal
ECG: Right bundle branch block, left axis deviation, PR 208ms, first degree AV block, repeated MPI interval 188ms, bifascicular block

Plan:
1. T&O review
2. Analgesia

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Summary:

Investigations: