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