Identifying Data:

Full Name: Ms. B

Address:  Queens, NY

Date of Birth: 1972

Date & Time: January 24, 2020

Location: QHC-IM, Queens New York

Religion: Christianity

Nationality: Barbadians

Marital status: divorced

Source of Information: Self

Source of Referral: self

Mode of Transport:  private car

Chief Complaint: “I am here for leg swelling” x 3 days

History of Present Illness:

47 Years old reliable female with PMHx of asthma, anemia, ALS (2004) with generalized weakness, dysarthria with no history of intubation present to the ED yesterday complaining of left leg swelling X 3 days. Pt developed an excruciating left groin pain on 01/15/2020 and was seen in QHC ED but she was discharged on Motrin under the impression of musculoskeletal pain. Yesterday patient came in again as the Left groin pain did not improve despite being on Motrin also patient developed an entire left lower extremity swelling. Pain currently 4/10. The patient denies chest pain, palpations, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, dysphagia, dizziness, syncope, or any recent travel history.

Past Medical History:

Present illnesses – ALS, anemia

Past Medical History: Asthma

Childhood illnesses – none

Immunizations –up to date; flu vaccine 2 months ago

Screening tests and results –Pap-smear- unknown

Past Surgical History: none

Medications:

Ergocalciferol 5000units- oral solution PO once a week, for Vitamin D dietary supplement

Megestrol 5ml (Megace) – oral solution PO two times daily, for poor appetite

 Allergies: no known allergies

Family History:

Mother –70 alive with HTN

Father –78 alive with HTN

Sister- 40 alive and healthy

Daughter- 24 alive and healthy

Daughter- 22 alive and healthy

Daughter- 20 alive and healthy

Maternal/paternal grandparents – Deceased at unknown age & unknown reasons

 

Social History:

Ms. B is a divorced female, living with her mother, father, sister, daughters and a grandchild in a private house.

Habits –no history of smoking or alcohol or illicit drug use

Travel – she recently did not travel.

Diet – She has a fast-food diet and a traditional Barbadian diet.

Exercise – She is currently bed-bound and can ambulate short distances with assistance and uses a wheelchair for traveling longer distances. She usually sleeps well.

Review of Systems:

General – Admits of generalized weakness/fatigue, and loss of appetite, all the time.  Denies fever, chills, recent weight or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness, discolorations, pigmentations, moles, sweating, changes in hair distribution rashes and pruritus.

Head –Denies headaches, vertigo or head trauma.

Eyes –denies lacrimation, visual disturbances (diplopia), pruritis, and photophobia. Last eye exam 3 months ago– does not know her visual acuity; normal pressure.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses –Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies bleeding gums, sore tough, sore throat, mouth ulcers, voice change Last dental- June 2019

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies wheezing, dyspnea, cough, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies irregular heartbeat, chest pain, palpitations, edema/swelling of ankles syncope or murmur

Gastrointestinal system –Has regular bowel movements in every day. Denies change in appetite, intolerance to spicy food, dysphagia, pyrosis, flatulence, eructation, and constipation nausea and vomiting, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in the stool.

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

Sexual Hx – She is not currently sexually active. Denies history of sexually transmitted diseases.

Menstrual/Obstetrical – G3P3. Menarche age 13.

Nervous –Admits of loss of strength and weakness. Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, change in cognition / mental status/memory, or weakness.

Musculoskeletal system – admits of left groin pain & calf swelling and pain, erythema. Denies muscle pain, or deformity.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – admits anemia but denies blood transfusions, history of previous DVT/PE, easy bruising or bleeding, lymph node enlargement.

Endocrine system – Denies heat intolerance, oliguria, hirsutism polyuria, polydipsia polyphagia, or goiter

Psychiatric – denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

 

Differential diagnosis

1. Deep vein thrombosis: unilateral leg swelling, erythema, warm
2. Venous insufficiency-
3. Cellulitis
4. Trauma
5. Musculoskeletal pain

Physical

General:  47 years old well-developed female, A/O x 3, facial features symmetric. Pt is small build, height and weight within underweight range, appears to be reported age, bed bound and good hygiene. Pt appears clean, slurred speech, cooperative, and appear to be in mild physical distress.

 Vital Signs:     BP:                              R

Laying             130/84

 

 

R:        18/min unlabored                    P:         85, regular

 

T:        99.2 degrees F (oral)               O2 Sat: 100% Room air

 

Height 63 inches    Weight 101 lbs.    BMI: 18.1

• Nails: no sign of clubbing, cyanosis, koilonychia, paronychia. capillary refill <2 seconds throughout.
• Skin: warm & moist and smooth to touch, good turgor. However, left leg was warmer and  bigger in size compare to right leg and erythematous in appearance. Nonicteric, no evidence of hypo or hyper pigmentation, mass, lesions, scars or tattoos.
• Hair: medium quantity, course and evenly distributed without any sign of alopecia, no nits or seborrhea noted.
• Head: normocephalic, atraumatic, no specific facies. non -tender to palpation throughout

Eyes –

Symmetrical OU; no evidence of strabismus, exophthalmos, ectropion, entropion, ptosis, edema, inflammation, crusting, discharge; Lacrimal gland does not seem enlarged. Sclera white; conjunctiva & cornea clear.

Visual fields are intact in all four quadrants.  PERRLA, EOMs intact with no nystagmus

Ears:

Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation

Auditory Acuity: whisper test, intact to whispered voice AU.

 Nose:

Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Sinuses – Non tender to palpation

Mouth & pharynx:

Lips –   Pink, moist; no evidence of cyanosis or lesions.

Mucosa – Pink ; well hydrated.   No masses; lesions noted.

No evidence of leukoplakia  or oral candiditis

Palate – Pink; well hydrated.   Palate intact with no lesions; masses; scars.

Teeth – good dentition

Gingivae –Pink; moist.  No evidence of hyperplasia; masses; lesions; erythema or discharge.

Tongue-Pink; no lesions or deviation noted.
Oropharynx – Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies.

Tonsils present with no evidence of injection or exudate.  Uvula pink, no edema, lesions

Neck, trachea, thyroid:

Neck – Trachea midline.   No masses; lesions; scars; pulsations noted. Non-tender to

Palpation no thrills or bruits, no adenopathy noted.

Thyroid – Non-tender; no palpable masses; no bruits noted.

THORAX & LUNGS:

Chest –      Symmetrical chest wall movement, no evidence of deformities, kyphosis, scoliosis, masses, lesions, cyanosis. no evidence of trauma.   Respirations rate normal and unlabored  with no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2 :1 no evidence of barrel chest.   Non-tender to palpation.

Lungs –   Clear to auscultation, Tactile fremitus intact throughout.  No adventitious sounds.

 Heart:  Regular rate and rhythm (RRR); S1 and S2 are normal, no evidence of  JVP  and carotid pulses are 2+ bilaterally without bruits, but no evidence of S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen: Flat / symmetrical / no evidence of caput medusae or abnormal pulsations. BS present in all 4 quadrants.  No bruits noted over aortic/renal/iliac. Tympany to percussion throughout. Non-tender to light/deep palpation.   No evidence of hepatomegaly. No masses noted.   No evidence of guarding or rebounds tenderness.   No CVAT noted bilaterally.

 Breasts/ female genitalia / rectal: Patient refused the exams

Peripheral Vascular: the entire left leg size greater than the right leg. Also, the entire left leg is erythematous and warm to touch. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. no clubbing, cyanosis noted bilaterally (no C/C/E  B/L) No stasis changes or ulcerations noted.

Musculoskeletal system: entire left leg swelling  and erythema  but no ecchymosis / atrophy / or deformities in bilateral upper and lower extremities.  No active range of  motion in upper and lower extremities bilaterally.  Muscle strength is 1/5 all throughout the body.

Neurologic:

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and

expressive abilities intact. Thought coherent. Evidence of dysarthria but dysphonia or aphasia noted.

 Cranial Nerves:

I – Intact no anosmia.

II-. Visual fields by confrontation full.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally.

IX-X-XII- Swallowing reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug is not intact.

Cra

Motor/Cerebellar

No active/passive ROM of all extremities. Low muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength (1/5 throughout). Pt is bedbound so did not evaluate, Pronator Drift, Gait, Romberg, coordination.

 Sensory

Intact to light touch, sharp/dull, point localization, extinction.

Meningeal Signs

Brudzinski’s and Kernig’s signs negative.

 

Labs:

CBC: WBC/HGB/HCT/PLT: 6.98/9.5*/31.1*/452*

CHEM/LYTES- Na/K/CL/CO2/BUN/Cr/Glu/Ca/Mg- 143/3.3*/105/24/13/0.53/96/9.1

LFT:alb/TP/TBiL,DBil/ALKP/ALT/AST:3.5/6.8/<0.3/–/85/65*/63*

COAG: PT/INR/aPTT: 12.6/1.1/24.9*

 

Imaging:

Lower extremity Venous Duplex Left

 

Intraluminal echogenicity in the left common femoral vein, proximal femoral vein, mid femoral vein, distal femoral vein and popliteal vein with non-compressibility.

 

Impression: acute venous thrombosis involving the left lower extremity

 

Problem list:

1. Left Leg swelling
2. ALS
3. Anemia
4. Hypokalemia

 

Assessment:

47 Years old reliable female with PMHx of asthma, anemia, ALS (2004) with generalized weakness, dysarthria with no history of intubation present to the ED yesterday complaining of left groin pain X1 Week and left leg swelling X 3 days. Lower extremity Venous Duplex Left result consistent with extensive left leg DVT.

Plan:

• Extensive left leg DVT
  • Anti-coagulation therapy: Pt and her family were informed about the risks (bleeding, intracranial bleed, GI bleed) and benefits (prevention of further clot formation, prevention of the propagation of clot) of anticoagulation.
  • Pt is unable to tolerate pills even if it crashed into food since she was a child therefore, the patient agreed to have anticoagulation via Lovenox injection. Administer Lovenox 1 mg/kg SubQ every 12 hours
  • The patient is unable to inject herself secondary to weakness from ALS so patient family member with be trained to inject the medication
  • Cardiac monitor
  • No need for GI prophylaxis at this time

 

• ALS
  • Baseline: ambulates with assistance for short distance, uses a wheelchair for longer distance, regulate diet and dysarthric speech. Assist with feeding and ambulation assistant all the time.
  • Fall precaution
• Asthma
  • Last exacerbation many years ago and there are no sign and symptoms of an acute exacerbation at this time
• Hypokalemia
  • Oral potassium 40mg
  • Repeat CMP for q6hrs