Subjective

CC: “My feet are really swollen and painful for the last 3 days, and it hurts to put my shoes on and just walk. 66 years old woman with Hx dyslipidemia, type II DM, C/O intermittent cramping when walking and pain to the deep touch, throbbing pain, intermittent numbness, and tingling.”

HPI:

The patient is a 66-year-old woman with a medical history of dyslipidemia and type II diabetes mellitus. She presents with complaints of significant swelling and pain in her feet that have been persistent for the past three days. The pain is exacerbated when she attempts to put on shoes and walk. Additionally, she reports experiencing intermittent cramping while walking, as well as throbbing pain, numbness, and tingling. These symptoms have been causing discomfort and hindered mobility. The patient’s description of her symptoms aligns with intermittent claudication, suggesting a potential vascular issue. A comprehensive assessment and evaluation are essential to determine the underlying cause and develop an appropriate management plan.

Past Medical History:

• Medical problem list

  Dyslipidemia, Type II Diabetes Mellitus.

• Surgical:

  No significant surgical history.

Allergies:

No known allergies to the environment, food, or drugs.

Medications:

1. Metformin (500 mg twice daily) for diabetes
2. Atorvastatin (20 mg daily) for dyslipidemia

Vaccinations:

Received all childhood vaccines.

Social History:

Chemical history:

The patient reports no current use of alcohol, drugs, tobacco, or excessive caffeine consumption.

Family History:

   Mother: Age 60, Deceased

Condition: Breast Cancer

Father: Age 61

Conditions: High Cholesterol, Osteoarthritis

Sister: Age 42

Condition: Migraine

Maternal Grandma: Deceased, Age 67

Condition: Osteoporosis

ROS:

General: No significant weight loss, fatigue, or fever.

Eyes: No visual disturbances or changes.

EarsNose/Throat/mouth:

       (+) FOR RHINORRHEA. No sinus pain or epistaxis. (+) SORE THROAT, 

       (+) HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth.

       The last dental exam was 2 months ago.

C/V: No chest pain, palpitations, or edema.
Pulmonary:(+)NON-PRODUCTIVE COUGH, Denies shortness of breath or persistent cough.

Neuro: Reports intermittent numbness and tingling in feet.

Lymph: No enlarged lymph nodes.

Allergy/immunology: No known allergies or immune system disorders.

Objective

VS: HR 80 bpm, BP 120/80 mmHg, Temp 98.6°F, RR 16 breaths/min, SpO2 98%, Pain 3/10.

Labs, radiology, or other pertinent studies:

Skin:  No rashes or lesions noted.

HEENT

Ears: Bilateral canals clear, no discharge.

Nose: Patent, no signs of congestion.
Throat: Oropharynx pink, no exudates.

Neck: Supple, no palpable lymph nodes.
Neuro: Cranial nerves intact, no focal deficits.

Cardio. Regular rate and rhythm, no murmurs.

Thorax and lungs: Clear breath sounds bilaterally.

A:

Differential DDX:      INCLUDE AT LEAST 3 DIFFERENTIALS

1. Tension-type headache – The patient’s presentation encompasses mild headache, fatigue, and unremarkable findings on physical examination, with the absence of focal neurological deficits.
2. Dehydration – Given the patient’s manifestation of a mild headache, fatigue, and normative physical examination outcomes, alongside a historical account of limited fluid intake, dehydration emerges as a plausible consideration.
3. Viral upper respiratory infection (URI) – The patient’s clinical profile, marked by symptoms including sore throat, cough, clear nasal discharge, and a low-grade fever, in conjunction with the lack of discernible bacterial infection markers, directs attention towards a viral URI.

DX: Viral Upper Respiratory Infection (URI)s

Plan:

• Diagnostics

              An in-house throat swab for rapid strep yielded a negative result. The patient underwent a Chest X-ray, Complete Blood Count (CBC), and Basic Metabolic Panel (BMP) to evaluate underlying causes (Banerjee et al., 2020). These measures were aligned with clinical recommendations (Banerjee et al., 2020).

• Treatment

             The patient is advised to persist with rest and increased fluid intake, adhering to established guidelines (Perez Nieto et al., 2021). Symptomatic management encompasses the continued usage of Over-The-Counter (OTC) Dayquil/Nyquil, administered at 15ml PRN in accordance with packaging directions (Perez Nieto et al., 2021).

• Education

1. Safe Dosing: Emphasize the importance of adhering to recommended dosages for medications (Baars et al., 2020).
2. Nyquil Sedation: Caution against activities requiring alertness (e.g., driving, heavy machinery) due to potential sedative effects of Nyquil (Baars et al., 2020).
3. Tylenol Limitation: Advise not exceeding 4000 mg of Tylenol per day and avoiding other products containing Tylenol simultaneously (Baars et al., 2020).
4. Alcohol Avoidance: Instruct to refrain from alcohol consumption while taking medications (Baars et al., 2020).
5. Home Remedies: Encourage consumption of tea with honey and lemon to alleviate cough and sore throat (Baars et al., 2020).
6. Gargling: Recommend gargling with warm salt water 2-3 times a day for 30 seconds each time to soothe throat (Baars et al., 2020).
7. Cough Hygiene: Cover mouth when coughing and avoid sharing drinks to minimize transmission (Baars et al., 2020).
8. Follow-up

A follow-up interval of 3-4 days was stipulated, contingent upon the commencement of symptom amelioration (O’Connor et al., 2019). The escalation of symptoms or emergent concerns, notably respiratory distress, prompted immediate medical attention through an office visit or, if necessary, an emergency room visit or dialing 911, in consonance with established guidelines (O’Connor et al., 2019).

The synthesis of diagnostic measures, therapeutic interventions, patient education, and delineated follow-up provisions aligns with the clinical rationale for diagnosing Viral Upper Respiratory Infection (URI) (O’Connor et al., 2019).

References

Baars, E. W., Belt-Van Zoen, E., Willcox, M., Huber, R., Hu, X.-Y., & van der Werf, E. T. (2020). CAM treatments for cough and sore throat as part of an uncomplicated acute respiratory tract infection: a systematic review of prescription rates and a survey among European integrative medical practitioners. European Journal of Integrative Medicine, 39(5), 101194. https://doi.org/10.1016/j.eujim.2020.101194

Banerjee, D., Michael, J., Schmitt, B., Salimnia, H., Mhaissen, N., Goldfarb, D. M., Lachance, P., Faron, M. L., Aufderheide, T., Ledeboer, N., Weissfeld, A., & Selvarangan, R. (2020). Multicenter clinical evaluation of the revogene strep a molecular assay for detection of streptococcus pyogenes from throat swab specimens. Journal of Clinical Microbiology, 58(7). https://doi.org/10.1128/JCM.01775-19

O’Connor, R., O’Doherty, J., O’Regan, A., O’Neill, A., McMahon, C., & Dunne, C. P. (2019). Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations. BMJ Open, 9(2), e025396. https://doi.org/10.1136/bmjopen-2018-025396

Perez Nieto, O. R., Wong, A., Lopez Fermin, J., Zamarron Lopez, E. I., Meade Aguilar, J. A., Deloya Tomas, E., Carrion Moya, J. D., Castillo Gutierrez, G., G. Olvera Ramos, M., García Montes, X., Alberto Guerrero Gutiérrez, M., George Aguilar, F., Salvador Sánchez Díaz, J., Soriano Orozco, R., Ríos Argaiz, E., Hernandez-Gilsoul, T., Secchi del Rio, R., Ñamendys-Silva, S. A., & L.N.G. Malbrain, M. (2021). Aiming for zero fluid accumulation: First, do no harm. Anaesthesiology Intensive Therapy, 7(2). https://doi.org/10.5114/ait.2021.105252