News

E-Med – H&P

Posted by

Tiffany Liang on July 31, 2022

Identifying Data :

Full Name: Ms. MG

Address: New York, NY

Date of Birth: 11/30/1956

Age: 65 yo

Date & Time: June 29, 2022 10:00 am

Location: Metropolitan Hospital, New York, NY

Religion: None

Source of Information: Self

Reliability: Good

Source of Referral: Self-Admitted

Chief Complaint : “Left ankle pain,” x 2 days.

History of Present Illness

65 yo female patient with a PMHx of ESRD, COPD, DM Type 2, hypertension, CHF, hypothyroidism, and left trimalleolar ankle fracture (6/22/22) presents to the clinic complaining of left ankle pain x 2 days. Patient states that she twisted her ankle while standing on pulling her pants up on 6/22/22. Patient presented to the ED that same day with x-ray showing a comminuted fracture in the distal tibia and medial malleolus. Left ankle was splinted and scheduled for Left foot ORIF. Patient explains how in the last 2 days, she has been experiencing constant pain in the left ankle that is sharp and feels warm. She denies radiation of the pain. Patient has not tried adjusting the splint or taking any medications to alleviate the symptoms. Denies, fevers, body aches, chills, abdominal pain, nausea, diarrhea, constipation, numbness, tingling, chest pain, shortness of breath.

Past Medical History

Asthma
Chronic Kidney Disease
COPD
Depressive Disorder
DM Type 2
Essential Hypertension
Heart Failure with preserved ejection fraction
Hyperlipidemia
Hypothyroidism
Nephrolithiasis

Past Surgical History

Left Foot ORIF scheduled 6/30/22

Medications

Albuterol 1 puff q6 hrs or prn
Amlodipine (Norvasc) 10 mg PO 1x QD
Atorvastatin (Lipitor) 40 mg PO 1x QD
Basaglar Kwikpen 100 unit/ML 0.04 mL subcutaneous 1x QD
Carvedilol (Coreg) 25 mg PO 2x QD with meals
Clopidogrel (Plavix) 75 mg PO 1x QD
Furosemide (Lasix) 80 mg PO 1x QD
Gabapentin (Neurontin) 300 mg PO 1x QD
Insulin Pen Needle 32 G 4x QD
Meclizine (Antivert) 25 mg 1x QD
Nifedipine (Adalat) 30 mg 1x QD

Allergies

None

Family History

Son – age 40, alive
Sister, age 68, alive, hypertension, DM Type II

Endorses family history of depression and hypertension. Denies family medical history of cancer or respiratory complications.

Social History

Patient is a single Spanish and English speaking 65 year old female who currently resides in an apartment alone in New York, NY. Patient is retired and lives a very sedentary lifestyle due to health complications.

Habits : Patient denies drinking, smoking, use of drugs or marijuana.

Travel : Denies recent travel.

Diet : Patient eats a diet heavy in carbs and meats.

Exercise : Patient maintains a sedentary lifestyle due to health complications.

Sexual History : Heterosexual, single, and not sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, with good pallor, and in mild distress upon movement of lower left leg. Denies loss of appetite, weakness, fever, and chills.

Skin, hair, nails – Denies erythema, edema, dryness, pruritus, 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 use of dentures, difficulty swallowing, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.

Neck – Denies stiffness, pain, swelling, and limited range of motion.

Breast – Denies lumps, pain, or discharge.

Pulmonary System – History of asthma and COPD. Endorses dyspnea upon exertion. Denies dyspnea, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System – History of hypertension and CHF. Endorses edema of ankles and feet. Denies chest pain, palpitations, syncope.

Gastrointestinal System – Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, pyrosis, hemorrhoids, constipation, rectal bleeding.

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.

Musculoskeletal System – Comminuted Fracture in left distal tibia and medial malleolus (6/22/22). Endorses pain and warmth in the left ankle x 2 days. Experiences limited range of movement due to splint.

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia, history of DVT/PE.

Endocrine System – History of hypothyroidism not currently on medication. Denies polyuria, polydipsia, polyphagia, goiter, heat or cold intolerance, or excessive sweating.

Psychiatric – Endorses history of depression and not currently seeing therapist and psychiatrist. Denies history of anxiety. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears alert and in mild distress upon movement of left leg. Appears well-developed, well-nourished, and hydrated. Appears stated age.

Skin: Warm, good turgor, and good pallor. 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 : Uncorrected – 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: Full 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 – No goiter or lumps. Non-tender to palpation.

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, erythema or discharge. Cervix parous (or 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. Pap smear obtained. 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. Trace brown stool present in vault. FOB negative.

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 ⅗ of left leg secondary to pain. Strength 5/5 bilaterally of upper extremities and right lower extremity. 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 :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Muscoloskeletal :

6 fracture blisters 3 cm in diameter around the left ankle noted. Erythema and edema present in the left ankle. No ecchymosis or atrophy in bilateral upper and lower extremities. Limited range of motion secondary to fracture of the left ankle. Full active range of motion with no crepitus in bilateral upper and right lower extremities. Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 152/92, Temp – 98.9 °F, SpO2 – 98%, Respiratory Rate – 20, Heart Rate – 74, Height – 5’ 6”, Weight – 154 lbs, BMI – 24.9

Assessment & Plan

65 yo female patient with a PMHx of ESRD, COPD, DM Type 2, hypertension, CHF, hypothyroidism, and left trimalleolar ankle fracture (6/22/22) presents to the clinic complaining of left ankle pain x 2 days. Exam is positive for blister, erythema, edema, and tenderness upon palpation. Patient denies fever, headache, and body aches. Patients most likely experience fracture blisters and localized cellulitis that requires drainage and antibiotics.

Problem List :

Fracture Blisters of left ankle
Comminuted fracture of left distal tibia and medial malleolus
Diabetes Mellitus Type II
Chronic Heart Failure
COPD

D/Dx :

Fracture Blisters – Patient presents with multiple non-purulent blisters surrounding her left ankle upon removal of splint. The acute onset, patient history of recent fracture, and patient presentation makes this diagnosis high on the list of differentials.

Cellulitis – Patient presents with pain and warmth in her left ankle. Upon removal of the splint, erythema and edema were noted. As the patient has a large number of coexisting complications such as diabetes, she is at an increased risk of infection.

Compartment Syndrome Patient presents with acute onset of pain upon application of splint. Compartment Syndrome is caused by pressure buildup from internal bleeding or swelling of tissues and a medical emergency and should be included in the list of differentials for this patient. However, upon opening the splint, the ankle showed good perfusion with pulse and sensation. These findings make compartment syndrome less likely.

Diabetic Peripheral Neuropathy – Patient has a history of DM Type II and other health complications. There is a likelihood the patient is experiencing diabetic peripheral neuropathy in conjunction to her ankle fracture. However, the patient does not present with numbness and tingling. Furthermore, diabetic peripheral neuropathy has a more progressive rather than acute onset that makes this diagnosis less likely.

Dermatitis – Dermatitis is a common complication of splint application due to the dark and enclosed nature of the application. However, the patient presents with pain, warmth, and edema rather than dryness and itchiness. Dermatitis should be considered but is unlikely.

Plan :

Admit patient for monitoring and treatment of active cellulitis treatment of left ankle. Initiate Vancomycin to control cellulitis infection. Consult orthopedics for splint removal, left ankle assessment, and rescheduling of left ankle ORIF.