Differential Diagnosis

The patient's symptoms of severe left posterior leg pain and mild to moderate chest pain, combined with a history of recent tibial fracture repair surgery and significant substance use, suggest several potential diagnoses. These can be categorized as follows:

• Single Most Likely Diagnosis

  • Deep Vein Thrombosis (DVT): The patient's recent surgery, history of smoking, and immobility increase the risk of DVT, which typically presents with leg pain and swelling. The chest pain could be related to a pulmonary embolism (PE) if the DVT has embolized.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): Directly related to DVT, PE can cause chest pain and is a significant concern given the patient's risk factors.
  • Musculoskeletal Pain: Post-surgical pain or strain from overuse could contribute to the leg pain, and musculoskeletal issues could also explain the chest pain, especially if related to coughing or strain from smoking.
  • Alcohol Withdrawal: Given the patient's high daily alcohol intake, withdrawal could be a consideration if he has recently reduced or stopped drinking, leading to symptoms that might include pain.

• Do Not Miss Diagnoses

  • Aortic Dissection: Although less likely, this is a life-threatening condition that could cause both chest and leg pain due to the involvement of the aorta and its branches. The patient's long history of smoking increases the risk of vascular diseases.
  • Myocardial Infarction (MI): Chest pain is a classic symptom of MI, and while the patient's age and smoking history increase his risk, the leg pain might be an atypical presentation or related to another condition.
  • Spinal Epidural Hematoma: A rare but potentially devastating complication post-surgery, especially if the patient is on anticoagulation therapy or has a coagulopathy, which could be exacerbated by alcohol and marijuana use.

• Rare Diagnoses

  • Thrombophlebitis: Inflammation of veins due to a blood clot, which could cause leg pain but is less common than DVT.
  • Compartment Syndrome: A potential complication of surgery or trauma, leading to increased pressure within a muscle compartment, which could cause severe leg pain.
  • Osteonecrosis: Although rare, it could be a consideration if the patient has experienced trauma or has risk factors such as long-term steroid use or excessive alcohol consumption, leading to hip or leg pain.