Differential Diagnosis

The patient presents with ongoing leg pain, negative DVT, and failure of treatment with NSAIDs and Flexeril, considering her overweight status. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Chronic Venous Insufficiency (CVI): Given the patient's overweight status and the chronic nature of her symptoms, CVI is a plausible diagnosis. CVI can cause leg pain, swelling, and skin changes, which might not have been fully addressed by the initial DVT check.

• Other Likely Diagnoses

  • Lymphedema: This condition, characterized by swelling due to impaired lymph drainage, could be exacerbated by the patient's weight and might cause chronic leg pain.
  • Peripheral Artery Disease (PAD): Although more common in older adults, PAD could be a consideration, especially if the patient has other risk factors such as smoking, diabetes, or high blood pressure.
  • Chronic Compartment Syndrome: This condition, often related to exercise, could potentially cause chronic pain if the patient engages in regular physical activity, despite the initial consideration of muscular strain being less likely due to the duration of symptoms.

• Do Not Miss Diagnoses

  • Osteonecrosis: Especially if the patient has a history of steroid use or other risk factors, osteonecrosis could be a critical diagnosis not to miss, as it requires prompt treatment to prevent further bone damage.
  • Bone Cancer or Metastasis: Although less likely, bone cancer or metastasis to the bone could cause chronic pain and must be considered, especially if there are other systemic symptoms or risk factors.
  • Deep Infection (Osteomyelitis or Cellulitis): Chronic infections can cause ongoing pain and might not always present with typical signs of infection, making them important not to miss.

• Rare Diagnoses

  • Ehlers-Danlos Syndrome: A genetic disorder affecting connective tissues, which could lead to chronic pain and musculoskeletal issues, though it's less likely without other characteristic features.
  • Complex Regional Pain Syndrome (CRPS): A condition characterized by intense burning or aching pain in the hands or feet after an injury or trauma, which could be a rare consideration if the patient has a history of trauma to the affected area.