Subjective Data (S)

Patient has swollen lower extremities, redness and ulcers.

Identifying Data:

Initials: N/A

Age: 90 years

Race: Caucasian

Gender: Female

CC/Chief Complaint: 90 year old female presents with bilateral swelling, redness and ulcers to lower extremities (ulcers are new).

HPI: Patient is a 90-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus and gastroesophageal reflux disease. She also has chronic arthritis with multi-joint discomfort and difficulty walking. She is on chronic opioid therapy. She felt not to be a candidate for joint replacement due to multiple medical issues and advanced age. She was brought to the emergency department today for evaluation of increasing pain, redness, swelling and bruising of the lower extremities. She has chronic venous stasis dermatitis but now appears to have bilateral lower leg cellulitis. She is planning short-term rehabilitation. She will be admitted for IV antibiotic therapy and pain management.

Location: Joints and lower extremities.

Duration: 1 week

Character: N/A.

Aggravating factors: Moving. 

Relieving factors: N/A

Timing: Ongoing, past few weeks.

Severity: Pain is at a medium to high level (7 to 8 in FACES pain scale), pt reports inability to participate in usual activities.

Review of Systems:

Constitutional: No fever or weight loss.

Skin: Bilateral lower leg redness pain swelling and small blisters which have ruptured and oozing.

Eyes: No recent vision problems or eye pain.

ENT: No congestion, ear pain or sore throat.

Endocrine: No thyroid problems. Type II diabetes mellitus.

Cardiovascular: No chest pain. No palpitations.

Respiratory: No cough, congestion or wheezing.

Gastrointestinal: she complains of reflux and a hiatal hernia and periumbilical pain which is intermittent.

Genitourinary: No dysuria. No urinary frequency.

Musculoskeletal: Generalized chronic joint pain.

Neurologic: No headache. No focal weakness.

 

Past Medical History

Past Surgical History:

• Hospital observation service, per hour (05/19/2018)
• Introduction of Anesthetic agent into joints, percutaneous approach (04/16/2018)
• Introduction of Anti-inflammatory into joints, percutaneous approach (04/16/2018)
• Appendectomy
• Hernia repair
• Hysterectomy
• Knee replacement
• Shoulder surgery

Social history:

• Alcohol (Use alcohol screen below for admitted Pats) – No risk, 05/19/2018
• Blood management: Accepts blood
• Employment/School – No risk, 05/19/2018
• Home/Environment – No risk, 05/19/2018
• Substance abuse – No risk, 05/19/2018
• Tobacco – No risk, 05/19/2018; unknown if ever smoked, household tobacco concerns: No

Allergies: None

Past Medical History

Ongoing

• Arthritis
• Benign essential hypertension
• COPD (Chronic obstructive pulmonary disease)
• Degenerative joint disease
• Diabetes mellitus
• Diabetic neuropathy
• Emphysema
• Encounter for preventive health examination
• Esophagitis
• GERD (Gastroesophageal reflux disease)
• Hypertension
• Hypothyroidism
• Mixed hyperlipidemia
• Osteoarthritis of hip
• Type 1 diabetes mellitus

Family History: Cardiovascular disease and diabetes mellitus

Immunizations: Up to date

Lab results:

CBC	WBC	HGB	HCT	PLT
SEP 27 12:18	7.5	11.1	36.4	196
BMP	Na	K	Cl	CO2	BUN	CR	Gluc	Ca
SEP 27	139	4.3	97	32	25.1	1.02	178	8.6
ABG	pH	PaCO2	PaO2	HCO3
---- No Results ----
COAG	INR	PT
---- No Results ----
Troponin
---- No Results ----
BNP
---- No Results ----
LFT	Alb	ALK	ALT	AST	DBili	TBili	Prot
SEP 27 12:18		3.7	71	14	21	0.5	6.5

 

Objective data: (O)

Physical Examination:

Vital Signs: T:98.0°F,  P:88, R:20, BP: 91/74, SpO2:98%, WT:103.64kg, BMI:44.86

General:  Pt is in no acute distress, morbidly obese, awake and alert. Vitals reviewed.

Eyes: Pupillary response normal. Sclerae normal

Ears: Normal findings

Nose: Sinuses don’t elicit pain to palpation

Throat: White tonsillar exudate and erythema, palatal petechiae

Neck: Non-tender to palpation

Lymph nodes: No cervical or supraclavicular adenopathy.

Cardiovascular: Normal heart tones, normal pressure, slightly elevated heart rate

Lungs: Normal to auscultation

Abdomen: Soft, obese and protuberant. Active bowel sounds all quadrants, palpation to abdomen without tenderness, including liver, percussion to abdomen normal, palpation of spleen without tenderness. There is a ventral surgical scar with a periumbilical hernia without tenderness, no HSM.

Neuro: CN II-XII intact grossly, she moves all 4 extremities with discomfort, some loss of sensation in the feet bilaterally. Pt is alert and oriented to surroundings,

Psychiatric: Oriented x3, normal mood and affect.

Extremities: No petechia or edema

Skin: Bilateral lower extremity erythema and swelling with a few small ruptured blisters.

Assessment

Diagnosis:

1. Cellulitis of multiple of lower extremity (L0.3119)
2. Diabetes Mellitus type 2, goal A1C to be determined (E11.9)
3. Edema of lower legs due to peripheral venous insufficiency (I87.2)
4. Morbid obesity due to excess calories (E66.01) 

Plan

The patient is a 90-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus and gastroesophageal reflux disease. She also has chronic arthritis with multi-joint discomfort, and difficulty walking. She is on chronic opioid therapy.

She was brought to the emergency department today for evaluation of increasing pain redness swelling and bruising of both lower extremities. She has chronic venous stasis dermatitis but now appears to have bilateral lower leg cellulitis. She is planning short term rehabilitation. She will be admitted for IV antibiotic therapy and pain management.

I will order vancomycin and ceftriaxone. She will be continued on all of her usual Medications hydromorphone 4 mg every 4 hours as needed for pain. She also takes Lyrica and Celebrex. I will order a fentanyl patch as I believe the patient's pain may be better controlled with a long-acting medication. Hopefully on the patch she will require fewer doses each day of hydromorphone.

I will continue her Lantus insulin at 80% of her usual dose and monitor her with Accu-Checks and coverage. She will be placed on a low-sodium diabetic diet. I will order Lovenox for DVT prophylaxis. She will be evaluated by physical therapy and occupational therapy. She will most likely require short-term rehabilitation placement. Additional plan will depend upon her course over the next 24 to 48 hours.

 

 

Medications

Colace, 100 mg Oral, Daily

Dextrose 50% in Water, IV Push, Once, PRN

Dextrose 50% in Water, IV Push, Once, PRN

Dextrose 50% in Water, IV Push, Once, PRN

Duloxetine, 60 mg Oral, Daily

DuoNeb, NEB, RTq6hr (respiratory ther)

Fentanyl Patch, 25 mcg TD, 972hr

Fentanyl Patch Removal, TD, 972hr

Furosemide Tab, 40 mg Oral, Daily

Glucagon, 1 mg IM, Once, PRN

Glucagon, 1 mg IM, Once, PRN

Glucose 40% gel, Oral, Once, PRN

Glucose 40% gel, Oral, Once, PRN

HYDROmorphone, 4 mg Oral, q4hr (specified start), PRN

Incruse Ellipta, 62.5 mcg INH, Daily

Insulin lispro medium dose coverage, Subcutaneous, Before meals and bedtime

Lantus, 40 unit Subcutaneous, BID

Lisinopril, 5 mg Oral, Daily

Lovenox, 40 mg Subcutaneous, Daily

Lyrica, 100 mg Oral, BID

Magnesium oxide, 500 mg Oral, QHS

MiraLax, 17 gm Oral, QHS, PRN

Multivitamin, Oral, Daily

Nystatin 100,000 units/g topical powder, TOP, TID

Omeprazole 40 mg oral delayed release capsule, 40 mg Oral, Daily

Saline Flush 0.9%, IV, q12hr, PRN

Saline Flush 0.9%, IV, Daily

Simvastatin, 10 mg Oral, Daily

Synthroid, 125 mcg Oral, QAM

Tamsulosin, 0.4 mg Oral, QPM

Vancomycin IVPB, 1 gm IV Piggyback, q12hr

Home Medications Active

Aspirin Enteric Coated 81 mg oral delayed release tablet 81 mg = 1 tab, Oral, Daily

Celebrex 100 mg, Oral, q12hr

Colace 100 mg oral capsule 100 mg = 1 cap, Oral, Daily

Combivent 1 inh, PRN, INH, q6hr

Duloxetine 60 mg oral delayed release capsule 60 mg = 1 cap, Oral, Daily

Furosemide 40 mg oral tablet 40 mg = 1 tab, Oral, Daily

HYDROmorphone 4 mg oral tablet 4 mg = 1 tab, PRN, Oral, q4hr (specified start)

Lantus 50 UNITS, Subcutaneous, BID

Lisinopril 5 mg, Oral, Daily

Lyrica 100 mg, Oral, BID

Magnesium oxide 500 mg oral tablet 500 mg = 1 tab, Oral, QHS

Miralax 17 gm, PRN, Oral, QHS

Multivitamin 1 tab, Oral, Daily

Nystatin 100,000 units/g topical powder 1 app, TOP, TID

Omeprazole 40 mg oral delayed release capsule 40 mg = 1 cap, Oral, Daily

Simvastatin 10 mg, Oral, Daily Spiriva 18 mcg inhalation capsule 1 puff(s), INH, RTDaily Symbicort , INH, BID

Symbicort 160 mcg-4.5 mcg/inh inhalation aerosol 2 puff(s), INH, Daily

Synthroid 125 mcg, Oral, QAM

Tamsulosin 0.4 mg oral capsule 0.4 mg = 1 cap, Oral, QPM

Voltaren Topical 1% topical gel 1 app, TOP, QID

 

Diagnostic Tests:

• Monospot test: for of heterophile antibody test, a rapid test for mononucleosis to detect for the presence of the Epstein Barr Virus (EBV), 70-90% sensitive, if negative could proceed with EBV serological testing. If this spot test is positive, most likely patient has infectious mono.
• CBC with differential: if this is mono, the total number of lymphocytes is elevated with atypical lymphocytes greater than 10%. A peripheral smear should be obtained if other blood disorder are suspected.
• Rapid Strep-85% sensitive for streptococcal pharyngitis, can be done easily in office, if positive, antibiotic therapy can be initiated and throat culture would not be required. If this is negative, consider the throat culture if indicated by the Centor criteria and risks such as exposure or contact with others was noted.
• Diagnostic test 4: throat culture: indicated according to modified Centor criteria, confirms presence or absence of pharyngeal streptococcus
• Diagnostic Test 5: Lateral neck films or CT scan: consider these tests to rule out or confirm retropharyngeal abscess or epiglottitis 

Summary

The patient is a 90-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus and gastroesophageal reflux disease. She also has chronic arthritis with multi-joint discomfort, and difficulty walking. She is on chronic opioid therapy.

She was brought to the emergency department today for evaluation of increasing pain redness swelling and bruising of both lower extremities. She has chronic venous stasis dermatitis but now appears to have bilateral lower leg cellulitis.

On physical exam she has temperature of 98.0°F, her abdomen is soft, obese and protuberant. Active bowel sounds all quadrants, palpation to abdomen without tenderness, including liver, percussion to abdomen normal, palpation of spleen without tenderness. There is a ventral surgical scar with a periumbilical hernia without tenderness, no HSM. Pt moves all 4 extremities with discomfort, some loss of sensation in the feet bilaterally. Her skin presents bilateral lower extremity erythema and swelling with a few small ruptured blisters.

 

Patient Education: Patient was educated about the nature of her condition and the management of her pain with opioids.

 

Bibliografía

Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2018). CURRENT Medical Diagnosis and Treatment 2019 (Fifty-eighth edition ed.). (S. Allen, Ed.) New York, New York, United States of America: McGraw Hill Professional.

Woo, T. M., & Robinson, M. V. (2015). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (Fourth edition ed., Vol. I). (R. H. Craven Jr., Ed.) Philadelphia, Pennsylvania, United States of America: F.A. Davis Company.

 

References

1. Papadakis, M. A., McPhee, S. J., and Rabow, M. W. (2018). CURRENT Medical Diagnosis and Treatment 2019 (Fifty-eighth edition ed.). (S. Allen, Ed.) New York, New York, United States of America: McGraw Hill Professional.
2. Woo, T. M., and Robinson, M. V. (2015). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (Fourth edition ed., Vol. I). (R. H. Craven Jr., Ed.) Philadelphia, Pennsylvania, United States of America: F.A. Davis Company.