What is the appropriate evaluation and management approach for a patient presenting with nontraumatic leg pain, considering their age, occupation, activity level, past medical history, allergies, medications, and social history?

History of Present Illness for Nontraumatic Leg Pain

Chief Complaint and Pain Characteristics

Document the precise location (anterior, posterior, medial, lateral compartment), quality (sharp, dull, aching, burning), intensity (0-10 scale), distribution (localized vs diffuse), duration, and temporal pattern (constant vs intermittent, time of day worsening). 1 Specifically inquire about:

• Onset: Gradual vs sudden, relationship to physical activity level, occupational demands, or changes in exercise routine 1, 2
• Exacerbating factors: Walking distance before pain onset, stair climbing, prolonged standing, specific movements, weight-bearing activities 1
• Relieving factors: Rest, elevation, specific positions, heat/cold application, over-the-counter medications 1
• Associated symptoms: Numbness, tingling, weakness, color changes, temperature differences, swelling, joint stiffness, morning stiffness duration 1
• Functional impact: Inability to work, disruption of hobbies/sports, sleep disturbance, limitations in activities of daily living 1

Red Flag Screening

Immediately assess for vascular emergencies and serious pathology:

• Critical ischemia symptoms: Rest pain, pallor, pulselessness, paresthesias, paralysis, poikilothermia 3
• Infection signs: Fever, erythema, warmth, rapidly progressive swelling 4
• Neurological deficits: Progressive weakness, saddle anesthesia, bowel/bladder dysfunction 1
• Constitutional symptoms: Unexplained weight loss, night sweats, fever suggesting malignancy or systemic disease 1

Past Medical History (Pertinent Details)

Systematically document conditions that influence treatment selection and prognosis:

• Cardiovascular: Congestive heart failure, hypertension, coronary artery disease, peripheral vascular disease, prior thrombotic events 1, 5, 6
• Renal: Chronic kidney disease stage, baseline creatinine, history of acute kidney injury 1, 5, 6
• Gastrointestinal: Peptic ulcer disease, GI bleeding history, inflammatory bowel disease 1, 6
• Hepatic: Cirrhosis, hepatitis, baseline liver function 1, 5
• Musculoskeletal: Osteoarthritis (specify joints), rheumatoid arthritis, gout, prior fractures, degenerative joint disease 1
• Psychiatric: Depression, anxiety, history of substance use disorder, chronic pain syndromes 1
• Neurological: Peripheral neuropathy, radiculopathy, restless leg syndrome, spinal stenosis 1
• Metabolic: Diabetes mellitus, thyroid disorders, iron deficiency anemia (ferritin <50 ng/mL) 1

Allergies

Document all drug allergies with specific reactions (rash, anaphylaxis, GI intolerance) to NSAIDs, acetaminophen, opioids, topical agents, and contrast media. 1

Current Medications

Obtain complete medication list including prescription, over-the-counter, and supplements:

• Analgesics: Current use of acetaminophen (daily dose), NSAIDs (type, dose, duration), opioids, topical agents 1, 5
• Cardiovascular: Anticoagulants, antiplatelet agents, diuretics, ACE inhibitors, beta-blockers 1, 5
• Other: Corticosteroids, disease-modifying antirheumatic drugs, supplements (glucosamine, chondroitin) 1
• Assess for drug-drug interactions and medication overuse patterns 1, 5

Past Surgical History

Document all prior surgeries, particularly:

• Orthopedic procedures: Joint replacements, arthroscopy, fracture repairs, ligament reconstructions 1
• Vascular procedures: Bypass grafts, stenting, thrombectomy 3
• Spinal surgeries: Laminectomy, fusion, discectomy 1
• Complications from prior surgeries and recovery course 1

Recent Hospitalizations

Inquire about admissions within the past 6-12 months:

• Reason for admission, length of stay, treatments received 1
• Falls or trauma requiring medical attention 7
• Thromboembolic events, infections, cardiac events 5, 3

Family History

Document first-degree relatives with:

• Osteoarthritis, rheumatoid arthritis, other inflammatory arthropathies 1
• Vascular disease, thrombophilia, early cardiovascular disease 3
• Chronic pain syndromes, psychiatric disorders 1

Social History

Assess factors critical for treatment planning:

• Occupation: Physical demands, repetitive activities, prolonged standing/sitting, heavy lifting 1, 2
• Activity level: Athlete vs sedentary, specific sports (running, skiing), exercise frequency and intensity 1, 2
• Tobacco use: Current, former, pack-years (impacts surgical outcomes and healing) 6
• Alcohol consumption: Quantity, frequency (hepatotoxicity risk with acetaminophen) 1, 5
• Substance use: Current or past opioid use, illicit drug use, aberrant medication-seeking behaviors 1
• Living situation: Stairs in home, support system, ability to perform ADLs independently 1
• Employment status: Working, disabled, workers' compensation involvement, litigation 1
• Weight and BMI: Obesity as modifiable risk factor for joint pain 1, 6

Review of Systems (Pertinent Positives/Negatives)

Systematically assess for associated symptoms:

• Constitutional: Fever, chills, night sweats, unintentional weight loss 1
• Musculoskeletal: Other joint pain, morning stiffness >30 minutes, joint swelling, mechanical symptoms (locking, catching) 1
• Neurological: Weakness, numbness, tingling, balance problems, falls, restless sensations in legs worse at night 1, 7
• Vascular: Claudication distance, rest pain, color changes with position, temperature asymmetry 3
• Sleep: Difficulty falling asleep, frequent awakenings due to pain, total sleep hours, daytime fatigue 1
• Psychological: Mood changes, anxiety, catastrophizing thoughts, fear of movement, depression screening 1
• Functional: Ability to walk specific distances, climb stairs, perform work duties, participate in desired activities 1

Psychosocial Assessment

Evaluate factors predicting chronicity and treatment response:

• Pain catastrophizing, fear-avoidance beliefs, kinesiophobia 1
• Depression and anxiety symptoms (consider validated screening tools) 1
• Coping mechanisms, prior pain management strategies, treatment expectations 1
• Impact on relationships, work status, disability claims, legal involvement 1
• Patient goals: pain reduction, functional improvement, return to specific activities 1