Differential Diagnosis for Lower Right Leg Pain

The patient is a 43-year-old male with worsening lower right leg pain, currently incarcerated, and on multiple medications. Given the information, the differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Peripheral Artery Disease (PAD): Given the patient's age, symptoms of worsening leg pain, and the fact that he is on Eliquis (an anticoagulant) and Atorvastatin (a statin), which suggests a history of cardiovascular disease, PAD is a strong consideration. The pain's severity, necessitating assistance for walking, further supports this diagnosis.
• Other Likely Diagnoses
  • Musculoskeletal Injury: The patient's need for assistance with walking due to pain could indicate a musculoskeletal injury, such as a strain or sprain, especially if he has been involved in any physical activities or altercations within the prison.
  • Neuropathic Pain: Amitriptyline, an antidepressant also used for neuropathic pain, is part of his medication regimen, suggesting a possible diagnosis of neuropathic pain, which could be contributing to his leg pain.
  • Deep Vein Thrombosis (DVT): Although he is on Eliquis, which reduces the risk of DVT, the fact that he is incarcerated (potentially less mobile) and has a history of cardiovascular disease does not entirely rule out DVT, especially if there has been a change in his mobility or other risk factors.
• Do Not Miss Diagnoses
  • Osteomyelitis or Septic Arthritis: Infections of the bone or joint can present with severe pain and are critical to diagnose early to prevent long-term damage. Given the patient's living situation, the risk of infection might be higher.
  • Compartment Syndrome: A medical emergency characterized by increased pressure within a muscle compartment, which can lead to muscle and nerve damage. Severe pain, especially with pallor, poikilothermia, paresthesia, paralysis, and pulselessness, would suggest this diagnosis.
• Rare Diagnoses
  • Eosinophilic Fasciitis: A rare condition characterized by inflammation of the fascia, which could present with severe pain and skin changes. The patient's use of various topical creams might hint at skin involvement, but this would be an uncommon diagnosis.
  • Chronic Regional Pain Syndrome (CRPS): A rare condition characterized by persistent burning pain and inflammation following an injury, which does not seem to fit perfectly with the patient's presentation but could be considered if other diagnoses are ruled out.

Next Steps

Given the differential diagnoses, the next steps would involve:

• A thorough physical examination to assess for signs of PAD, musculoskeletal injury, neuropathic pain, or infection.
• Review of the patient's complete medical history, including any recent injuries, infections, or changes in medication.
• Laboratory tests (e.g., complete blood count, erythrocyte sedimentation rate, blood cultures if infection is suspected) and imaging studies (e.g., Doppler ultrasound for PAD or DVT, X-rays for musculoskeletal issues) as indicated by the physical examination and history.
• Consideration of consulting a specialist (e.g., vascular surgeon, orthopedic surgeon, neurologist) depending on the suspected diagnosis.
• Adjustment of the patient's current medications or addition of new medications based on the diagnosis (e.g., pain management, antibiotics if an infection is identified).