Identifying Data :

Full Name: Ms. PC
Address: Queens Village, NY
Date of Birth: 5/25/196
Age: 56 yo
Date & Time: March 13, 2022 9:00 AM Location: Queens Hospital Center, Queens, NY Religion: None
Source of Information: Self
Reliability: Good
Source of Referral: Self-Admitted

Chief Complaint : “Pain in my right thigh.” x2 months

History of Present Illness

56 yo female patient with PMHx of poorly controlled diabetes mellitus type II, hypertension, unintentional weight loss, and gastric ulcer (Graham Patch Repair 2021) presents to the Emergency Department complaining of dizziness, fall, and sharp pain in the right thigh. Patient states that she has experienced dizziness for the past year. She fell nearly 2 months ago and did not experience any bleeding or lacerations. However, she describes that the thigh pain was so severe that she needed to go to the Emergency Department 1 month ago. She was discharged with pain medications. She states that the pain has not subsided and has become unbearable, rating it an 11/10. She is no longer able to walk far distances or stand for more than 10 minutes at a time. Patient denies injuring the affected area since the first fall. She continues to show no signs of bruising, discoloration, swelling, or lacerations at the site. Experiences tenderness upon palpation to the area and limited range of movement. Patient endorses feeling weak and dizzy. Denies fever, diaphoresis, chest pain, palpitations, headache, shortness of breath, nausea, vomiting, constipation, dark stool, or urinary symptoms. Denies recent travels.

Past Medical History

• Diabetes Mellitus Type 2
• Diabetic Retinopathy
• Malnutrition & Unintended Weight Loss
• Shoulder Impingement – 4 years ago
• Cataract of Both Eyes
• Fall – 2 months ago

Past Surgical History

• C- Section – 1992
• Exploratory Laparotomy with Graham Patch – 2021

Medications

• Carvedilol (Coreg) 3.125 mg PO BID
• Dapagliflozin Propanediol (Farxiga) 10 mg PO QID
• Famotidine (Pepcid) 20 mg QID
• Humalog Kwikpen 100 unit/mL – 0.08 mL Injection TID before meals
• Insulin Glargine (Lantus Solostar) 100 unit/mL – 0.3 mL QID before bed
• Sacubitril-Valsartan (Entresto) 24 – 26 mg PO q 12 hours
• Sitagliptin-Metformin (Janumet XR) 50 – 1000 mg PO BID
• Spironolactone (Aldactone) 25 mg PO QID

Allergies

Pineapple – swelling

Family History

• Mother – deceased
• Father – deceased
• Younger Sister – younger, estranged
• Son – alive, 30 yo
• Family history of hypertension and diabetes mellitus
• Denies family medical history of cancer or respiratory complications

Mother – deceased
Father – deceased
Younger Sister – younger, estranged
Son – alive, 30 yo
Family history of hypertension and diabetes mellitus
Denies family medical history of cancer or respiratory complications

Social History Patient is a single English & speaking 56 yo female who currently lives alone in an apartment in Queens Village, NY. She has one living older sister and a son who does not live in the state of NY. Patient is currently employed as a housekeeper.

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

Travel : Denies recent travel.

Diet : Patient eats a balanced meal of carbs, protein, and vegetables. However, the patient states she often does not have an appetite and eats very little.

Exercise : Patient maintains an active lifestyle due to her occupation as a housekeeper.

Sexual History : Heterosexual, single, and not sexually active. Not currently on birth control and has not been sexually active in several years. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears in great pain, moaning, and very weak. Endorses poor appetite. Denies fever and chills.

Skin, hair, nails – Denies sweating, excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Endorses dizziness. Denies headaches, head trauma, coma, or fractures.
Eyes – Endorses cataracts and impaired vision. 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 – unknown.

Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion. 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 – Denies chest pain, palpitations, edema/swelling of ankles or feet, 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 – unknown. Post-menopausal beginning 5 years ago.

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

Musculoskeletal System – Experiences constant sharp pain in the upper right thigh for the past 2 months. Experiences tenderness to palpation and limited range of movement in the area. Denies muscle weakness, slowness, swelling, and erythema.

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 or history of DVT/PE.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.

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

Physical Exam
General: Female patient appears in severe pain, moaning, and weak. Appears malnourished

and underweight. Appears stated age.

Skin: Poor pallor. Warm, dry, and good turgor. Non-icteric, no lesions, masses, scars, 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 sparse, 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 : Impaired due to cataracts.
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 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: Dry, pale. No cyanosis, masses, lesions, swelling, or fissures.

Mucosa: Pink, dry. No masses 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 – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Good range of motion. 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, 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 active/passive ROM of all extremities without rigidity or 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 :

Brachioradialis Triceps
Biceps Abdominal

Meningeal Signs :

RL RL

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

Patellar
Achilles
Babinski
Clonus negative

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

Muscoloskeletal : No erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper extremities and left lower extremities. Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 110/70 Temp – 97.4 °F
SpO2 – 98% Respiratory Rate – 18 Heart Rate – 69

Height – 5’ 2” Weight – 104 lbs

BMI – 19.5
POC Glucose – 357

Assessment & Plan

56 yo female patient with PMHx of diabetes mellitus, hypertension, and gastric ulcer (Graham Patch Repair 2021) presents to the Emergency Department complaining of dizziness, fall, and sharp pain in the right thigh. Exam is positive for tenderness to palpation and limited range of movement in the right thigh.

Problem List :

D/Dx :

• Right thigh pain
• Dizziness
• Hypertension
• Uncontrolled Diabetes Mellitus Type II
• Unintentional Weight Loss
• Cataracts in both eyes

1. Femur/Hip Fracture or Dislocation – Patient has a history of fall and is currently underweight and malnourished. There is a chance she fractured or dislocated her femur or hip.
2. Deep Vein Thrombosis – Patient has a history and family history of hypertension. Poor circulation and thrombus formation is a possibility for the cause of her right thigh pain. However, her right thigh does not present with warmth of swelling which makes this diagnosis likely, but not the first on the list of differentials.
3. Diabetic Peripheral Neuropathy – Patient has a history of uncontrolled diabetes mellitus type II. It is highly likely she is experiencing complications from this and experiencing pain in the right thigh area.
4. Soft Tissue Infection – Patient has a history of falling, malnourishment, and poorly controlled diabetes mellitus type II. The combination of a fall and poor baseline health creates the potential for a site of infection and poor healing time.
5. Osteomyelitis – This differential diagnosis is an extension of the potential for a soft tissue infection. As the patient presents with a poor baseline health and history of fall over two months ago, there is the possibility that a site of infection progressed to her bone to cause the severe pain in her right thigh. However, this is a severe diagnosis with progression of disease that places this diagnosis at the lowest of the list of differentials.

Plan :

Admit the patient for imaging studies of the right thigh (x-ray and CT with contrast) for potential bone fracture/dislocation, soft tissue infection, and osteomyelitis. Order venous doppler studies for the possibility of a DVT that could be causing leg pain. Initiate Levemir and Lispro to control

diabetes mellitus type II in the patient. Consult the surgical team for possible fracture, dislocation, or debridement.

1. EKG, CBC, BMP, CMP
   • Ensure that patient is hemodynamically stable
   • Monitor patient’s glucose levels due to uncontrolled diabetes mellitus type II
   • Assess for blood lab abnormalities that could indicate possible infection
2. Administer Levemir & Lispro

• Control patient’s diabetes mellitus type II to optimize patient’s baseline health and wound healing

3. Hip & Right Thigh X-Ray

• Assess for possible fractures or dislocations

4. Venous Doppler Studies

• Assess for perfusion and possibility of DVT

5. CT with contrast Hip & Right Thigh

• Assess for possible soft tissue infection and osteomyelitis

6. Consult Orthopedics & Surgery

• Prepare for possible debridement or fracture/dislocation