I was surprised to find urgent care to be one of my favorite rotation sites. I believe this was largely due to the fact that a good portion of providers were recent York grads. For this reason, they were able to provide a great learning environment for students to learn hands on. The urgent care also had an incredible patient volume that allowed me to see a variety of patients ranging from immunizations to stitches to congestive heart failure. Furthermore, this site encouraged students to write-up the electronic medical records for patients examined. In doing so, I practiced a realistic routine and expecation of a PA. Although patient care remains the top priority, a majority of our work remains in documenting patient visits. The urgent care allowed me to hone my skills in the interview, physical exam, and documentation of HPI and billing. Urgent care also stood out from my previous rotation sites in that it provided acute rather than long term care. Its intention is treat patients quickly so they do not need to wait in the emergency room and or setup an appointment far into the future for a refill. The downside is that patient’s conditions cannot be managed overtime and we must trust that the patient takes our recommendations in self-care and PCP follow-ups. Overall, the urgent care created a fast-paced and hands-on environment that was excellent for allowing students to practice as if they were the real provider.

CLINICAL CASE SCENARIO

26 year old male patient with no significant past medical history presents to the clinic complaining of three painful bumps on his right bicep and underarm for one week. 

QUESTIONS TO ASK

• Have you been outside recently?
• Do you remember being bit by a bug?
• Have you changed the type of soap, lotion, or detergent you use recently?
• Have you hurt the affected area in the past or recently?
• Are the bumps itchy?
• Is the pain constant, worse with movement, or comes and goes?
• Have you tried anything to alleviate the symptoms?
• Has this ever happened to you before?

HISTORY OF PRESENT ILLNESS

• Constant sharp pain
• Not pruritic
• No bug bites
• No edema, erythema, ecchymosis
• No trauma to the area
• No change is soap or lotions
• No history of STIs
• Has not taken anything to alleviate the pain
• No joint pain
• No fever, body aches, chills, headache, nausea, vomiting, diarrhea, constipation
• No chest pain or shortness of breath
• Never happened before

PAST MEDICAL HISTORY

• None

CURRENT MEDICATIONS

• None

ALLERGIES

• NKDA

SOCIAL HISTORY

26 year old male patient resides in Middle Village, Queens in an apartment with his roommate. He currently works from home as an accountant. Patient states he eats balanced meals in carbs, protein, and vegetables but is minimally active due to his occupation. Patient endorses drinking occasionally for social events and denies a history of smoking and drug use. 

REVIEW OF SYSTEMS

• General  – Denies chills, fever, lightheadedness.
• ENT  – Denies ear pain, sore throat, swollen glands, changes in vision.
• Cardiovascular  – Denies chest pain, palpitations, shortness of breath. 
• Gastrointestinal  – Denies abdominal pain, diarrhea, constipation, nausea, vomiting. 
• Skin  – Presence of 2 painful indurated bumps in the right underarm and 1 painful indurated bump on the right inner arm. Denies rash, erythema, edema.
• Neurologic  – Denies dizziness, headache, numbness, tingling. 

PHYSICAL EXAM

• Vital Signs – HR 71 bpm, BP 134/88, R 18, T 97.7
• General – Alert, well developed, well nourished, in no acute distress.
• Eyes – pupils equal, round, reactive to light and accommodation.
• Heart – no murmurs, regular rate and rhythm, S1, S2 normal.
• Lungs – clear to auscultation bilaterally.
• Musculoskeletal – no ecchymosis, edema, erythema, deformities, acute abnormality notes, pain. Full range of motion with 5/5 strength. 
• Skin – Right Underarm: skin intact with no deformity. Noted 2 erythematous papules. Areas are tender to palpation. No drainage noted. Papules are indurated. Right Upper Arm: skin intact with no deformity. Noted 1 erythematous papule. Areas are tender to palpation. No drainage noted. Papule is indurated. 

DIFFERENTIAL DIAGNOSIS

• Abscess – Abscesses are collections of pus in tissue due to bacterial infection. The underarm is an area prone to infection due to moisture and skin to skin contact. Currently, the patient presents with an indurated lump that is not filled with pus. It is possible that the lump is at the early stages of infection. For this reason, the patient should be placed on oral antibiotics to resolve the abscess prior to the need for incision and drainage. 

• Furuncle – Furuncles typically present as red and painful lump due to infection of a hair follicle. This patient fits this presentation as it is a very painful lump. However, the lump was not fluctuant. This may be due to the fact that the bump is still in the early stages of infection and not filled with pus. 

• Hydradinitis Supporativa – Patient presents to the clinic with underarm bumps. Hydradinitis Supporativa should be included in the list of differential diagnoses. Hidradenitis Suppurativa presents with painful lumps due to inflammation and infection of the sweat glands. However, this is a chronic condition that enlarges, fills with pus, and may result in scarring. The patient may be continued to be monitored for this condition. But as the lumps remained isolated, few, and indurated, this condition is lower on the list of differentials. 

• Folliculitis – Patient presents with bumps in the underarm region that is prone to moisture, heat, and irritation. There is a high likelihood the patient has an infected hair follicle. However, the bumps are large, indurated, and with a dark center that does not entirely correlate with the presentation of folliculitis. Folliculitis typically appears as multiple small papules. 

• Epidermoid Cyst – And epidermoid cyst is a benign lump that is painless. As the patient presents with significant pain, this diagnosis is placed lower on the list of differentials. 

TESTS

• Skin Culture of debrided material or blood is indicated if the bumps present with severe local infection, systemic signs of infection, or failure of initial antibiotic therapy. The culture would identify the exact strain of bacteria causing the infection to guide antibiotic therapy. 

DIAGNOSIS

• Skin Abscess – Patient presents with painful lumps in both areas of hair follicles and isolated soft tissue. Patient has never experienced this before and the bumps presented acutely in the past week. Although the bumps are indurated and do not require incision and drainage, abscess is the most likely diagnosis. 

TREATMENT

• Oral Antibiotics (One of the following)
  • Clindamycin 300 mg PO q 8 hours
  • Augmentin 500 mg q 8 hours
  • Doxycycline 100 mg q 12 hours
  • Cephalexin 250 mg q 6 hours 

• Oral Pain Relief (One of the following)
  • Tylenol q 4 – 5 hours
  • Ibuprofen q 6 – 8 hours

PATIENT COUNSELING

• Instruct patient on antibiotic dosage
• Advise patient to use warm compresses 2x each day on affected area
• Recommend patient to avoid use of deodorant until completion of antibiotics 
• Have patient monitor bumps for signs of infection (pus, erythema, fever) 
• Encourage patient to return to the clinic or present to the emergency room if signs of infection present or worsen

This study was a systematic review performed in 2017 to determine if probiotic monotherapy or probiotic adjunct therapy to existing antibiotic therapy improves eradication rates of H. pylori. H. pylori infection can result in chronic dyspepsia, gastritis, mucosa-associated lymphoid tissue lymphoma, and gastric adenocarcinoma.  However, there is growing antibiotic resistance to current standard treatment. For this reason, several new therapeutic approaches are being adopted in clinical practice to see if they offer any benefits in treating H. pylori infection. One of these approaches is using probiotics. Probiotics are living bacteria that may be consumed and have a significant impact on gut health.

The study determined that probiotic therapy alone is not effective in the eradication of H. pylori infections. However, pretreatment and supplementation during antibiotic therapy with probiotics demonstrated higher eradication rates with reduced antibiotic therapy side effects. Patients were more likely to adhere to the antibiotic therapy with the reduction of adverse effects. This study does address its limitations in that only a small number of publications were included and did not account for recurrence rate of infection. For this reason, a stronger designed-study with a larger pool of participants over a longer period of time is necessary to establish the role of probiotics in the eradication of H. pylori. 

CASE SCENARIO

A 40 yo female patient presents to urgent care with a three-inch laceration on her left calf. The sterile gloves available are too large for the provider at hand. There are fitting non-sterile gloves available. 

SEARCH QUESTION :

Does the use of non-sterile gloves in minor procedures (such as the suturing of small lacerations) present with greater incidence of infection in comparison to the use of sterile gloves?

QUESTION TYPE : 

Prevalence Screening Diagnosis

Prognosis Treatment Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices. 

If meta-analysis or systematic review are not available, I would expand my search to include retrospective cohort studies and randomized controlled trials. Alternatively, a randomized controlled trial may also be included. Patients may be randomly assigned to receiving a procedure with the use of non-sterile or sterile gloves to observe for procedure infection and adverse outcomes. The downside to using a randomized controlled trial in this PICO search is that the participants may not have been included based on the same research design or eligibility criteria. Factors such as coexisting medical complications of patients, variability in provider training and technique, and differences in laceration size  can dramatically influence and alter the data and conclusions. However, a strong design must be implemented at first to ensure that patients receive as close as possible treatment in sterile preparation, local anesthesia, surgeon performing the procedure, and patient post-operation education and wound care. This would allow for minimal bias and influence factors to ensure that the type of procedure performed is the factor assessed in the study.  

PICO SEARCH TERMS :

SEARCH TOOLS & STRATEGIES USED :

Please indicate what databases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters. 

For this PICO search, I included systematic analysis, meta-analysis, and randomized controlled trials. I prioritized recent data along with the level of study to draw the most relevant and data-driven conclusion. Although RCTs are not the highest level of study, I believe it still yielded relevant and important data as the studies presented with contemporary research design, outpatient medical settings, and appropriate protocols. I found PubMed and JAMA to yield the best search results as it included several filters to specify search results. Google Scholar provided ample search results but with limited filter options. As a result, I had to manually review articles to search for appropriate studies to include in this PICO study as many results were not aligned with the clinical case scenario proposed. 

RESULTS FOUND :

Article 1 : The Necessity of Sterile Gloves for the Closure of Simple Lacerations

Article 2 – Comparison of Sterile vs. Non Sterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures

Article 3 – Comparing Non-Sterile with Sterile Gloves for Minor Surgery : A Prospective Randomized Controlled Non-Inferiority Trial

Article 4 – A Pilot Study on the Repair of Contaminated Traumatic Wound in the Emergency Departing Using Sterile Versus Non-Sterile Gloves

Weight of Evidence:

I would weigh Article 2 : Comparison of Sterile vs. Non Sterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures as the strongest study. This is because it was a meta-analysis with the largest pool of participants. It presents as a high-level of study that was performed recently with detailed inclusion criteria. Furthermore, it included a large number of participants and a wider range of study types that diversified the patient type and methodology of studies to provide a wide range of data with a more holistic perspective. 

Next, I would select Article 1 The Necessity of Sterile Gloves for the Closure of Simple Lacerations as the next strongest study. This study presented as a systematic review that provided a detailed review of three randomized controlled trials. This presents as a high level of study that was performed in recent years to provide relevant and current data. Furthermore, the study focused on minor laceration repair in an acute care setting. This emphasized small laceration sizes in a uniform outpatient setting to assess the significance of using non-surgical versus surgical gloves.

I would then rank Article 3 Comparing Non-Sterile with Sterile Gloves for Minor Surgery : A Prospective Randomized Controlled Non-Inferiority Trial as the next strongest study. Although it was a randomized controlled trial and not considered as high a level of study as systematic review and meta-analysis, it included a very standardized procedural protocol to ensure participants were receiving the same care. 

Last, Article 4, A Pilot Study on the Repair of Contaminated Traumatic Wound in the Emergency Departing Using Sterile Versus Non-Sterile Gloves presents as the weakest study. This was a meta-analysis that included 222 participants. The study includes a much smaller pool of participants in comparison to the other articles. As a result, the participants may not provide a holistic sample size of the general public. Furthermore, the study did not outline specific inclusion and exclusion criteria to ensure that participants were eligible. 

What is the clinical “bottom line” derived from these articles in answer to your question?

The clinical bottom line is that the use of non-sterile gloves is appropriate in the setting of urgent care for minor laceration suturing procedures. The four studies concluded that risk for infection remained low with the use of non-surgical gloves. Furthermore, the application of non-surgical gloves required less time and reduced costs. This presents as an attractive, efficient, and highly reasonable medical practice for patients who present with small laceration, without significant risk factors, and who require fast treatment. For this reason, I would suggest that the use of non-surgical gloves in the patient presented in this clinical case scenario is appropriate. However, if the patient is immunocompromised or presents with foreign body or debris in the wound, I would recommend the use of sterile gloves during the procedure.

Identifying Data :

Full Name: Ms. VY
Address: Maspeth, NY
Date of Birth: 1/31/1953
Age: 69 yo
Date & Time: June 6, 2022 12:00 PM Location: Centers Urgent Care, Queens, NY Religion: None
Source of Information: Self
Reliability: Good
Source of Referral: Self-Admitted

Chief Complaint : “Swollen hands and feet,” x 2 days.

History of Present Illness

69 yo female patient presents to the clinic complaining of swollen hands and feet x 3 days. She explains that she ate a diet heavy in sodium and in sugar on Friday night as she smoked marijuana and had “the munchies.” Patient states this has happened before but that this is the worst it’s ever been. Patient says the symptoms usually resolve on their own but is worried of a pending heart attack. Patient has a family history of heart attacks (father and brother causes of death) and cardiovascular disease. Patient explains she was a previous smoker for 50 years. She has not taken any medications to alleviate the symptoms. Denies trauma to the affected area, erythema, ecchymosis, pruritus, fever, headache, dizziness, chest pain, chest palpitations, diaphoresis, or shortness of breath.

Past Medical History

• None

Past Surgical History

• None

Medications

• None

Allergies

• Penicillin

Family History

• Mother – age 91, alive, hypertension
• Father – aged 69, deceased due to heart attack, hypertension, hypercholesterolemia, diabetes mellitus type II
• Older Brother – aged 60, deceased due to heart attack, hypertension
• Older Sister – age 72, alive, hypertension, hypercholesterolemia
• Daughter – age 50, alive, hypertension, asthma
• Son – age 46, alive, hypertension
• Endorses family medical history of cardiovascular disease and death due to heart attacks
• Denies family medical history of cancer or respiratory complications

Social History

Patient is a married English speaking 69 year old female who currently resides in a house with her husband in Queens, NY. Patient is retired and lives a minimally active lifestyle.

Habits : Patient endorses smoking for 50 years but quit for the past 2 years. Patient also admits to smoking marijuana daily. Patient drinks socially, having 1 – 2 drinks during family gatherings.
Travel : Denies recent travel.
Diet : Patient eats a meal heavy in carbs and protein. Patient admits to “having the munchies” while smoking marijuana and eats a large amount of junk food that is high in salt and sugar.

Exercise : Patient maintains a minimally active lifestyle.
Sexual History : Heterosexual, married, and sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, with good pallor, and in no acute distress. Denies weakness, loss of appetite, fever and chills.
Skin, hair, nails – Endorses edema of bilateral hands, ankles, and feet. Denies erythema, pruritus, dryness, sweating, scars, lacerations, lesions, or moles.

Head – Denies headaches, dizziness, head trauma, coma, or fractures.
Eyes – Uses reading glasses. Denies other visual disturbances, lacrimation, photophobia, or pruritus. Last eye exam – unknown.
Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – 1 year ago.
Neck – Denies stiffness, pain, and limited range of motion. Denies localized swelling/lumps.
Breast – Denies lumps, pain, or discharge.
Pulmonary System – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System – Endorses history of edema in hands and feet after meals high in sodium. Patient explains the swelling typically resolves on its own. Denies chest pain, palpitations, history of hypertension, syncope.
Gastrointestinal System – Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, hemorrhoids, constipation, rectal bleeding. Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.
Menstrual and Obstetrical — Menarche age 14. Last menstrual cycle took place around 20 years ago. Denies abnormal vaginal odor, discharge, bleeding or itching.
G4P2022
Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.
Musculoskeletal System –. Denies muscle pain, tenderness to palpation, limited range of movement, weakness, and erythema.
Peripheral Vascular System – Denies coldness or trophic changes or color changes.
Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia or history of DVT/PE.
Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.

Psychiatric – Endorses a history of anxiety and speaking with a therapist. Denies history of depression and speaks with a psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam
General: Female patient appears alert and in no acute distress. Appears well-developed, well-nourished, and hydrated. Appears stated age.
Skin: 1+ pitting edema notes in bilateral hands, ankles, and feet. Warm skin with good pallor and good turgor. Non-icteric, no scars, lesions, masses, tattoos, or bruising.
Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.
Head: Skull is normocephalic and non-tender to palpation. Hair is full, average texture, and average luster.
Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.
Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU
Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with a good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.
Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation.
Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures.
Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.
Palate: Pink, dry. No lesions, masses, scars.
Teeth: Teeth intact, no dentures. White and no cavities.
Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.
Tongue: Pink, well papillated. No masses, lesions, or deviation.
Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.
Neck – Full range of motion and non-tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.
Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.
Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.
Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds. Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Genitalia : External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, or erythema. Cervix multiparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Rectal : Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness.
Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.
CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.
CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.
CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.
CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy.
Motor/Cerebellar :
Full range of motion, not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.
Sensory :
Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.
Reflexes :

RL RL

Brachioradialis 2+
Triceps
Biceps
Abdominal
Meningeal Signs :
No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative. Muscoloskeletal :

Erythema and mild edema present on bilateral legs. Skin is dry, flaky, and pruritic. No ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper and lower extremities bilaterally. Full spinal range of motion with no deformities.
Vitals
Blood Pressure – 136/82, Temp – 99.3 °F, SpO2 – 98%, Respiratory Rate – 18, Heart Rate – 75, Height – 5’ 1”, Weight – 145 lbs, BMI – 27.4

Assessment & Plan

69 yo female patient presents to the clinic complaining of swollen hands and feet x 3 days. Exam is positive for bilateral edema in hands, feet, and ankles. Patient denies fever, chest pain, palpitations,

2+
2+
2+
2+/2+ 2+/2+

Patellar0 0 Achilles 0 0

2+ 2+

Babinski
Clonus negative

neg neg

shortness of breath, numbness, and tingling. Patient should receive a cardiac work-up and is most likely experiencing fluid retention from a poor diet.

Problem List :

• Bilateral edema in hands, feet, and ankles
• Poor diet in sodium and sugar D/Dx :

1. Congestive Heart Failure – Patient presents bilateral edema in the hands and feet. Furthermore, she presents with a concerning family history of cardiovascular disease and death due to heart attack. Patient also explains she has not seen a primary care doctor in years and does not maintain a healthy diet. This places congestive heart failure at the top of differentials to ensure that her presentation is not life-threatening.
2. Fluid Retention – Patient’s physical exam showed lungs that were clear to auscultation and a normal sinus rhythm cardiac sounds and normal heart rate. This reduces the likelihood that she is experiencing congestive heart failure. For this reason, fluid retention should be considered as the patient endorses a diet high in sodium and admits to previous episodes of edema.
3. Lymphedema – Patient presents with bilateral edema in the hands and feet. Lymphedema results due to the pooling of lymph fluid due to a diseased or blocked lymph system. This condition can be caused by inflammatory or malignant disorders. The condition also tends to be progressive and presents with skin thickening. For these reasons, lymphedema should be considered. However, further monitoring and assessment for co-existing medical conditions are necessary to rule-in this diagnosis.
4. Rheumatoid Arthritis – Patient is older in age and has not seen a primary care physician in years. Furthermore, her edema presents bilaterally. For this reason, rheumatoid arthritis should be considered. However, the patient does not present with bilateral pain, stiffness, or joint nodules. Rheumatoid Arthritis remains lower on the list of differential diagnoses.
5. Cellulitis – Patient presents with swollen hands and feet with minimal erythema. The swelling is also not painful. Cellulitis presents with warmth, erythema, pain, and fever. This makes cellulitis less likely. However, cellulitis should be included in the list of differentials as it is a life-threatening condition that is best managed when treated in its early stages.

Plan :

Assess the patient for cardiac abnormalities to rule-out life-threatening conditions. Emphasize patient education so that the patient can seek long-term care with a primary care physician and maintain a healthy and balanced diet to prevent future episodes of swelling.

1. EKG

a. Assess for the patient’s cardiac condition to ensure she is not having a cardiac emergency due to family history of heart attacks, personal history of poor diet, and presentation with bilateral hand and feet edema.

2. Patient Education
   1. Educate the patient on the importance of annual physical exams and having a primary care physician at her age and for her family’s medical history
   2. Emphasize to the patient’s need for control of her poor eating habits to prevent future swelling of hands & feet, cardiovascular disease, and unhealthy weight gain
3. Obtain A Primary Care Physician
   1. Encourage patient to find a primary care physician to monitor cardiac health due to extensive family history of cardiovascular disease
   2. Recommend the patient to follow-up with primary care to monitor for worsening symptoms
4. Emergency Department

a. Instruct the patient to go to the nearest emergency department if she experiences chest palpitations, chest pain, shortness of breath, vision changes, headache, or worsening edema