Artifacts
Reflection
I feel that my experience in family medicine was great exposure to primary care. It is interesting to see things more from the prevention and health maintenance perspective than the treatment and damage control side. For example, we manage blood pressure and encourage medication adherence to prevent a hospital presentation of hypertensive urgency/ emergency. Furthermore, I feel that at times the visits resemble urgent care visits, however, here we are always concerned with screening. Other specialties can focus on their perspective issues and stamp a “follow-up with primary care” for all other complaints, whereas primary care is the catch-all for all complaints/concerns. One thing I was surprised about was the high amount of referrals given. It seems that primary care is often to identify problems and look for red flags, that the specialist will take care of. One aspect I enjoyed was seeing the same patients repeatedly and getting to follow-up on that patient’s conditions/ progress.
As for what I would like to improve on for the following rotations, it would be my overall medical knowledge. I have had more specialized rotations earlier on, with many of my more general ones being saved for the end. I have Internal Medicine, Surgery, and Geriatrics left, and thus I feel now is really the time to hone in on general pathologies and start preparing for the PANCE. I feel that with these rotations there will be significant overlap, allowing more reinforcement of certain ideas. I would also like to continue maximizing my time by doing many of my assignments while I am at my rotation/ on lunch hour and saving my time at home for studying.
I think this rotation will help me in future rotations by helping me remember the importance of prevention. First off, I learned a lot about screening guidelines in this rotation. Additionally, I learned about the importance of encouraging the patient to take their medication consistently as prescribed as well as ensuring they have their refills. Furthermore, this rotation helped me learn about the management of common pathologies, such as diabetes, hypertension, hyperlipidemia, glaucoma, etc.
Site Visit
I presented 2 H&Ps, 1 journal article, and 5 pharm cards. The feedback was positive with minimal criticisms made. My first patient was very complex, with chronic venous insufficiency, hypertensive urgency, and possible DVT. My second patient presented with testicular pain. I think for my site evaluations in the future I would like to spend more time on researching thoroughly the pathologies in my H&Ps as seeing the patient’s presentation will help to anchor that information. Furthermore, I would like to pay attention to specific PE maneuvers that can help point towards or away from a diagnosis.
H&P
Identifying Data:
Name: DM
Address: Arverne, NY
Age: 68 y.o.
Sex: Female
Race: African-American
Date: 8/24
Location: South Shore Family Medicine
Source of Information: Self
Source of Referral: None
Reliability: Somewhat reliable
Chief Complaint: right leg swelling x 2 weeks and headache x 1 day
History of Present Illness:
68 yo female with PMH of HTN, HLD, epilepsy, osteoarthritis, asthma, varicose veins, GERD, and obesity presents with right leg pain and swelling. Pt complains of 7/10, pressure-like, intermittent, right leg pain from the knee down, with discoloration for the past two weeks. Pt reports pain is worse with walking and better with Advil and rest. Pt reports she has a bilateral doppler ultrasound on 8/17 from another physician which she has not yet received the results for yet.
Pt also has elevated BP reading of 210/100 at this visit and reports she has been taking her BP medication for the past week (last dose 6 am) and has just started this medication as she was not able to get a refill during COVID. Pt currently complains of constant, 5/10, pressure-like, non-radiating frontal headache for the past day. Pt denies alleviating/ aggravating factors/ taking anything for the pain. Pt denies f/n/v/d/chest pain/ seizures/ abdominal pain/ blurry vision/ back pain/dyspnea/ leg ulcers/ hx of heart disease or DVT/PE. Pt reports that she lives at home with her sister and states repeatedly “I am fine. I am fine. I do not want to go to the hospital.”
Past Medical History:
-PMH: HTN, HLD, epilepsy, osteoarthritis, asthma, varicose veins, and obesity
-Past Medical Illnesses/Hospitalizations: Pt reports being hospitalized for an asthma exacerbation in 2015 and a varicose vein surgery in 2017.
-Childhood Illnesses: denies childhood illnesses
-Immunizations: Up to date.
-Screening tests and results: Mammogram, 2018-negative. Colonoscopy, 2018, negative.
Past Surgical History:
Right varicose vein surgery 2017
Medications:
-Dilantin 100 mg PO TID
-Enalapril-Hydrochlorothiazide 10-25 mg PO daily
-Omeprazole 10 mg PO daily
-Ventolin HFA
-Rosuvastatin calcium 20 mg PO daily
Allergies:
-NKDA, denies environmental or food allergies.
Family History:
-Mother: Deceased at 86, epilepsy, DM
-Father: Deceased at 88, DM, HTN, OA
-sister- 64, HTN.
Denies family history of heart disease or cancer.
Social History: DM is a single, retired female who lives in an apartment with her sister.
-Habits: Former smoker of 40 pack years. Quit 5 years ago. Denies drug or alcohol use.
-Travel: Denies recent travel.
-Diet: Pt does not adhere to a specific diet, sometimes eating fruits and vegetables and sometimes eating fried foods.
-Exercise: Does not exercise because she finds it difficult because of her arthritis and obesity.
-Sleep: Usually sleeps about 8 hours a night.
-Safety: admits to wearing seatbelt.
-Sexual Hx: DM is currently not sexually active. Denies any history of sexually transmitted diseases.
ROS:
-General: Reports 10 lb weight gain over the past few months during quarantine. Denies loss of appetite, generalized weakness/ fatigue, fever, chills, weight loss, night sweats.
-Skin, hair and nails: Pt reports discoloration in right leg from the knee down. Denies changes in texture, excessive dryness, sweating, moles/rashes, pruritis, or changes in hair distribution.
-Head: Reports headache x 1 day. Denies vertigo or head trauma
-Eyes: Denies blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, or pruritus. Last eye exam was one year ago and wears reading glasses.
-Ears: Denies deafness, pain, discharge, tinnitus or use of hearing aids.
-Nose/sinuses: Denies discharge, obstruction or epistaxis.
-Mouth/throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, use of dentures. Last dental exam 2018, normal.
-Neck: Denies localized swelling/lumps or stiffness/decreased range of motion
-Breast: Denies lumps, nipple discharge, or pain.
-Pulmonary system: Admits to dyspnea, wheezing, and cough because of her asthma. Denies hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.
-Cardiovascular system: Admits to HTN, HLD, unilateral edema of right leg. Denies palpitations, irregular heartbeat, syncope or known heart murmur.
-Gastrointestinal system: Reports history of heartburn. Denies loss of appetite, nausea, vomiting, abdominal pain, and diarrhea. Denies intolerance to specific foods, dysphagia, flatulence, eructations, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
-Genitourinary system: Denies flank pain, urinary frequency or urgency, hematuria, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or changes in color of urine
-Sexual Hx: DM is currently not sexually active and denies sexually transmitted diseases.
-Menstrual/Obstetrical: Menarche 13 y.o. LMP at age 50. Pt reports she has completed menopause. Denies breakthrough bleeding/spotting or vaginal discharge.
-Obstetrical Hx: G0P0
-Nervous: Reports history of epilepsy but no recent seizures. Admits to headache for one day. Denies loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
-Musculoskeletal system: Reports right leg edema and discoloration. Reports chronic knee pain from osteoarthritis. Denies muscle pain.
-Peripheral vascular system: Reports history of varicose veins, pain with walking, peripheral edema, and color changes in the right leg. Denies coldness.
-Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
-Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric – Denies depression/sadness, OCD, anxiety, or ever seeing a mental health professional.
Physical
Vital Signs: BP: 210/100, 210/90
R: 16 breaths/min unlabored P: 64 bpm, regular
T: 96.8 degrees F (oral) O2 Sat: NA
Height: 62 inches Weight: 252 lbs. BMI: 46.09
General: 68 yo morbidly obese female, appear stated age of 68. Pt appears distressed and uncooperative with attempts to encourage her to go to the ER. Pt appears stable.
Head, Skin, Hair, and Nails:
Skin: warm & moist, good turgor with exception of right leg (see Peripheral Vascular)
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout
Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;
conjunctiva & cornea clear. Visual acuity-corrected – 20/30 OS, 20/30 OD, 20/30 OU.
Visual fields full OU. PERRLA, EOMs full with no nystagmus. Fundoscopy – Red reflex intact OU. Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears, Nose, & Sinuses:
Ears: Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM’s pearly white / intact with light reflex in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.
Nose: Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No step-offs or evidence of foreign bodies.
Sinuses: Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses. Normal air filled frontal and maxillary sinuses.
Mouth, Oropharynx, Neck, and Thyroid:
Mouth:
-Lips: pink, moist, no evidence of cyanosis or lesions. Non-tender to palpation.
-Mucosa: Pink, well hydrated. Palate intact with no lesions, masses, scars. Non-tender to palpation; continuity intact.
-Teeth: Good dentition / no obvious dental caries noted.
-Gingivae: Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge.
Non-tender to palpation.
-Tongue: Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.
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 midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.
Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Thorax& Lungs:
-chest: Symmetrical, no deformities, no evidence of trauma. Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. LAT to AP diameter: 2:1. Non-tender to palpation.
-lungs: Wheezing noted in left lower lobe. Remainder of lungs is clear to auscultation and percussion. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious breath sounds.
Heart: JVP is 2.6 cm above sternal angle with head of bed at 30 degrees. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. RRR. S1 & S2 normal. There are no murmurs, S3, S4 splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: flat / symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Peripheral Vascular:
Right leg- 2+ pitting edema, skin appears tight, dark brown, leathery and warm to the touch. 1+ pulses noted bilaterally. Pt is extremely tender to palpation.
Left leg- 1+ pitting edema, appear tight and dark brown, similar to other leg, but without warmth and tenderness.
No ulcers or cyanosis noted bilaterally.
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Brachial
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Ulnar
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Radial
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Femoral
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Popliteal
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D.P.
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P.T.
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| R
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2+
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1+
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2+
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2+
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1+ | 1 +
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1 +
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| L
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2+
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1 +
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2 +
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2+
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1+ | 1+
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1+
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Musculoskeletal Upper & Lower Extremities:
Right leg- 2+ pitting edema, skin appears tight, dark brown, leathery and warm to the touch. 1+ pulses noted bilaterally. Pt is extremely tender to palpation.
Left leg- 1+ pitting edema, appear tight and dark brown, similar to other leg, but without warmth and tenderness.
2+ pulses in bilateral arms. No crepitus noted throughout. Full ROM throughout.
Psych- Pt started crying during exam stating she did not want to spend anymore time in the hospital. Pt refused to go to the hospital consistently, despite urging from PA, EMTs, and paramedics. Pt finally complied and was taken to the hospital via ambulance.
Neurological System Exam:
Mental Status: A/O to person, place, and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphoria or aphasia noted.
Cranial nerves:
I . Olfactory: intact bilaterally
- Optic: Visual acuity OD: 20/30 OS: 20/30 OU: 20/30 (corrected). Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.
III. Oculomotor, IV Trochlear, VI Abducens: PERRLA, EOM intact without nystagmus.
- Trigeminal: facial sensation intact, strength good. Corneal reflex intact B/L.
VII. Facial: facial movements symmetrical and without weakness.
VIII. Acoustic: hearing grossly intact to whispered voice B/L. Weber Midline, Rinne: positive
- Glossopharyngeal, X Vagus, XII Hypoglossal: Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
- Spinal Accessory: shoulder shrug intact. SCM and trapezius muscles strong.
Motor/Cerebellar Exam:
Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait is slow and pt walks with cane. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative.
Sensory
Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally.
Reflexes R L R L
Brachioradialis 2+ 2+ Patellar 2+ 2+
Triceps 2+ 2+ Achilles 2+ 2+
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 negative.
Differentials:
- Chronic venous insufficiency with superimposed DVT- Pt has dark brown, leathery legs with hx of varicose veins. However, one leg is warm and extremely tender suggesting DVT. Rule in with venous duplex ultrasound to confirm both.
- Hypertensive Emergency- diagnosis established with 2 BP readings over 180/120 with end organ damage (headache).
- Peripheral arterial disease- consistent with pain with walking relieved by rest. However, PE is more consistent with CVD and skin does not appear cool to touch. Perform Ankle-brachial index to rule out.
- CHF- possible because of bilateral leg pitting edema and dyspnea. However, these findings are better explained by asthma and chronic venous insufficiency. Rule out with ECG, BNP, echo.
Assessment:
68 yo female with PMH of HTN, HLD, epilepsy, osteoarthritis, asthma, varicose veins, and obesity presents with hypertensive emergency and right leg pain and swelling consistent with chronic venous insufficiency and possibly DVT.
Plan
- Call ambulance because of hypertensive emergency and possible DVT. Stress to Pt severity and life-threatening nature of DVT/PE and hypertensive emergency.
- Perform ECG while waiting for ambulance.
- Repeat BP q10 mins
- Change BP medication from Enalapril-Hydrochlorothiazide 10-25 mg PO daily to Enalapril 20 mg PO daily and HCTZ 50 mg PO daily
- Epilepsy continue Dilantin 100 mg PO TID
- GERD Continue Omeprazole 10 mg PO daily
- Asthma Continue Ventolin HFA prn
- Hyperlipidemia Rosuvastatin calcium 20 mg PO daily
- Follow-up 2 days after hospital discharge.
Site Visit Summary
A Systematic Review and Meta-analysis of Exercise Intervention for the Treatment of Calf Muscle Pump Impairment in Individuals with Chronic Venous Insufficiency
This article is a systematic review/ meta-analysis including 14 articles for a total of 519 patients (ranging from age 27 to 91) evaluating how exercise may improve the calf muscle pump (CMP) allowing for improvement of chronic venous insufficiency. Exercises included calf strengthening, ankle stretching, and walking programs. Outcomes were evaluated using air plethysmography. The exercise group was found to have significantly better CMP ejection fraction. They were also found to have less residual venous fraction and better ankle range of motion, however these findings were not significant. Exercise training was found to be safe and there were minimal reported adverse effects. Some weaknesses include that only half the studies had professionals trained in exercises, like physical therapists, guiding the patient through the exercises.
This entry is licensed under a Creative Commons CC0 1.0 Universal Public Domain Dedication license.
