Identifying Data:

Full Name: Mrs. T.B

Address: Queens, NY

Date of Birth: 7/22/1951

Date & Time: 3/16/2021

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: “My arm is swollen after getting the COVID vaccine”. x 4 days

History of present Illness:

69 year old female with PMH of hypertension, hypercholesterolemia and no history of COVID presented to ED with a 4 day history of pain and swelling of her left upper arm. The pain and swelling started 9 days after receiving her first dose of Moderna COVID vaccine. Swelling had begun around the injection site and expanded to include the entire lateral side of her left upper arm. Pain was described as dull, constant, and localized to the arm, with an intensity of 4/10. Patient didn’t take anything for the swelling, and nothing made it better or worse. She also reported rash over her chest that started on the first day of receiving her vaccine. She took Tylenol on the first day and the rash went away.  She also had chills, generalized fatigue and occasional headache since she got the vaccine. Denied fever, recent trauma, or recent exposure to allergens. No chest pain, palpitation and SOB. Patient stopped taking all her medications 4 days ago because she didn’t know if they will exacerbate the swelling or not.

Past Medical History:

Hypertension x 20 years, well controlled on medications

Hypercholesterolemia x 20 years, well controlled on medications

Constipation – 3 month ago

Immunization – Up to date including flu shot

Screening Test – Colonscopy 2019, one polyp was removed.

Mammogram 2018, found a nodule in left breast and was followed up with a biopsy, was a benign nodule and didn’t proceed to surgery

Past Surgical History:

Left breast biopsy in 2018

Medications:

Livalo (Pitavastatin) 2 mg PO once daily for hypercholesterolemia. Last dose taken on 3/12/2020

Cartia XT (Diltiazem hydrocholoride) 120 mg PO twice daily for hypertension. Last dose taken on 3/12/2020

Linzess (Linaclotide) PO once daily for constipation (patient doesn’t remember the dosage). Last dose taken on 3/12/2020

Multivitamin PO once daily for general health (patient doesn’t remember the dosage). Last dose taken on 3/12/2020

Allergies:

Sulfa, selfish, cats

Family History:

Mother – Deceased at age 93, natural causes. Had history of hypertension

Father – Deceased at age 85, kidney failure

Brother – 60, alive and diagnosed with leukemia

Daughter – 37, alive and well

Denies family history of diabetes

Social History:

Mrs. T.B is a married female living with her husband.

Habits – Denies alcohol and tobacco use. Denies history of substance abuse and illicit substance use. She drinks coffee occasionally.

Travel – Denies recent travel.

Sexual Hx – Not sexually active. Menopause at age 55. Denies history of sexually transmitted disease.

Review of Systems:

General – Generalized fatigue and chill after receiving COVID vaccine (x13 days)

Denies recent weight loss or gain, loss of appetite, fever and night sweats.

Skin – Erythema, pain and swelling of her left arm, started from injection site and expanded to the entire lateral side of her left upper arm (x4 days). Denies moles/rashes, change of skin texture, pigmentation, excess dryness or sweating, open wound, itchiness.

Head – Has headache once or twice a week since she got the COVID vaccine. Headache lasts about half hour each time, goes away on its own. Headache is occasional, around temporal and occipital areas, with an intensity of 2/10. Patient didn’t take anything for it, and nothing makes it worse. Denies light-headedness, recent head trauma, sinus pain or nasal congestion.

Eyes – Patient is myopic, wears glasses. Last eye exam on 10/27/2020, does not know her intraocular pressure or visual acuity. Denies other visual disturbances, photophobia, redness, discharge and tearing.

Ears – Patient notices constant tinnitus in both ears for a long time. Tinnitus doesn’t interfere with her daily life. Denies deafness, pain, discharge, or use of hearing aids.

Nose – Denies discharge, obstruction, epistaxis, loss of smell, recent trauma to nose, itchiness.

Mouth/throat – Last dental exam in Jan, 2021, normal. Denies sore throat, bleeding gum, mouth ulcers, voice change or use of dentures.

Neck –Denies localized swelling/lumps, decreased range of motion.

Breast – Benign nodule in left breast. Mammogram and biopsy of left breast done in 2018. Denies pain, and nipple discharge.

Pulmonary system – Denies cough, sputum, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, hemoptysis and cyanosis.

Cardiovascular system – HTN x 20 years. Hypercholesterolemia x20 years. Occasional edema/swelling of her ankles. Denies heart murmur, chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system – Constipation 3 months ago. Occasional diarrhea. Colonoscopy done in 2019, one polyp was removed. Denies nausea or vomiting, loss of appetite, abdominal pain, rectal bleeding, dysphagia, hemorrhoids and jaundice.

Genitourinary system –Denies urinary frequency, urgency, oliguria and incontinence. Monogamous, not sexually active. Denies history of STI.

Menstrual/Obstetrical – G1 P1 (NSVD X1). Menarche age 15. Menopause at age 55. Denies abnormal vaginal discharge, itching, pain of vagina.

Nervous system – Denies seizure, weakness, sensory disturbances, memory change, and ataxia.

Musculoskeletal system – Pain and swelling of left upper arm x 4 days. Denies back pain, joint pain or varicose vein.

Hematological system –Denies history of clots, easy bruising or bleeding, anemia, blood transfusion, lymph node enlargement.

Endocrine system –Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating or hirsutism.

Psychiatric –Denies history of depression, anxiety, feeling of helplessness, hopelessness, lack of interest in activity, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 36.7 degree C

BP: 146/83 sitting up

Pulse: 76, regular

RR: 18/min, unlabored

O2: 98% Room air

General – Slender female, sitting up in bed, well groomed and in gown.

Skin – Left upper arm is swelling and warm to the touch. Poor turgor. Nonicteric, no lesions noted, no scars, tattoos

Hair – average quantity and distribution

Nails – no clubbing, capillary refill <2 seconds

Head – normocephalic, atraumatic, non-tender to palpation throughout

Ear – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex. Weber midline/Rinne reveals AC>BC in both ears.

Nose – Symmetrical, no masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink. No foreign bodies

Sinuses – Non-tender to palpation over bilateral frontal, ethmoid and maxillary sinuses

Eyes – Symmetrical OU, No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink.

Visual acuity corrected – 20/20 OS, 20/20 OD, 20/20 OU

Visual fields full OU. PERRLA. EOMs intact with no nystagmus

Fundoscopy – Red reflex intact OU. Cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, exudates or neovascularization OU.

Lips – Pink, moist, no cyanosis or lesions.

Mucosa – Pink, well hydrated, No masses; lesions noted. Non-tender to palpation. No leukoplakia.

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

Teeth – Good dentition. No obvious dental caries noted.

Gingivae – Pink, moist. No hyperplasia, masses, lesions, erythema or discharge.

Tongue – Pink, well papillated. No masses, lesions or deviation.

Oropharynx – Well hydrated. No injection, exudate, masses, lesions, foreign bodies. Tonsils present with no 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 cervical adenopathy noted.

Thyroid – Non-tender. No palpable masses, no thyromegaly, no bruits noted

Chest –Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart – JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th 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.

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

SOAP Note Exercise                                       

Case 1

CC: Sudden onset substernal chest pain that “woke me up “and lasted until now (about 45 mins) 

HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain.  The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath.  Nitroglycerin was administered sublingually, but only provided temporary relief.  Aspirin was given to the patient to chew in the ambulance.

PE:

VS: BP 150/70, HR 110, Temp 37.1 ͦC, R 30  Pulse oximetry: 96% on room air

Gen: obese, pale, diaphoretic patient

Lungs: clear to Auscultation and Percussion

Heart: RRR, S4 gallop noted

Ext: No cyanosis or edema

Labs:

CBC: Hemoglobin & hematocrit normal, WBC 11,000 (slightly high)

Electrolytes: Normal

Troponins: Troponin T and I are elevated

CK-MB: normal

EKG: sinus tachycardia, elevated ST segments in leads II, III, and AVF

Assessment: Acute Inferior wall MI

Plan:  Start Morphine drip IV, O₂ via nasal cannula, Metoprolol, urgent transfer to interventional cardiology lab

The patient has a balloon angioplasty and stent placement and is transferred to the telemetry unit for monitoring.  You see the patient the next day and need to document your visit in a progress note in the SOAP format. [See next page for information you need to write it]

The next day you visit the patient and must write a progress note to include the following:

A very brief synopsis of what occurred the day previously

His current medications:

Aspirin 81 mg orally, once a day

Plavix 75 mg orally, once a day

Lopressor 25 mg orally every 12 hours

His report of his condition today:  much more comfortable.  No pain, no shortness of breath.  Some mild fatigue when walking from room to nursing station

The EKG this morning shows normal sinus rhythm with no ST elevations and no Qwaves

The physical exam which includes: HR 72, BP 130/70, R 24, Temp 37.4   ͦC

General: appears comfortable. 

Extremities: peripheral pulses are slightly diminished and 1+

Heart: Regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral pulses intact and 2+ .  No hematoma

You believe he is doing well and that the same plan should be continued for now.  You would like the nurse to check his vital signs every 4 hours for one more day and then every 8 hours. 

If all goes well, patient is without chest pain and VS are stable, he can be discharged to home in 3 days.

SOAP note for the visit:

Subjective:

70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died MI at 60 y/o brought in by ambulance yesterday c/o pressure-like substernal chest pain that radiated to the left arm, along with nausea, diaphoresis, and SOB. Lab showed elevated troponin level, elevated ST segments in leads II, III, and AVF, and slightly elevated WBC. Temporary relief with sublingual nitroglycerin.  Was diagnosed with acute inferior wall MI and sent to interventional cardiology lab for balloon angioplasty and stent placement. Today, patient reports feeling much more comfortable, mild fatigue when walking from room to nursing station. Denies pain, SOB.

Meds: oral aspirin 81mg QD, oral Plavix 75mg QD, oral Lopressor 25 mg Q12H.

Objective:

HR 72, BP 130/70, R 24, Temp 37. 4   ͦC

General: appears comfortable

Extremities: peripheral pulses are slightly diminished and 1+

Heart: RRR, no gallops or murmurs.

EKG: normal sinus rhythm with no ST elevation and no Q waves (done this morning)

Lungs: clear

Groin: femoral pulses intact and 2+. No hematoma

Assessment:

Pt with acute inferior wall MI, post-operative day 1 for balloon angioplasty and sent placement.

Recovering well

Plan

1) Continue morphine drip IV, O2 via nasal cannula, Metoprolol

2) Check vital signs every 4 hours for one more day, then every 8 hours

3) If chest pain didn’t come back and VS are stable, discharge to home in 3 days

Patient Background:

Damien, age 33, was adopted by a NYC couple after birth to a single mother in Tennessee. He has been a long-haul truck driver and sometimes bus driver for private companies.  These jobs have not typically provided health coverage so even though he suffers from hypertension and gout, he has not been consistent about taking his medications for these conditions because he can’t always afford them.  He had regular health care through his teens when he was still on his parents’ insurance, but he hasn’t had a regular health care provider since turning 18 and has mostly managed by going to urgent care centers when he needs new prescriptions or has an acute problem.  He has just obtained a job in a UPS processing center which will mean that he’ll be on his feet all day rather than sitting and driving.  It also means he now has regular health insurance so he has come to see you today for a “once over” and to get prescriptions for his blood pressure and gout.

Damien rarely drinks alcohol, except on special occasions. He smokes cigars “when I want to relax” with friends at a cigar bar.  He estimates that he has about 4 cigars a week.  He drinks up to a gallon of (full fat) milk a day which he sees as a healthy behavior, but he otherwise has a basically poor diet. He eats a good deal of meat, is trying to cut back on sugary drinks, has developed a “beer belly” in spite of the fact that he rarely drinks beer. He loves snack food and pastries and cakes of all kinds.  He says he also loves edamame (fresh soy beans) and will enjoy salad but rarely chooses this in a restaurant, or buys it when shopping for food to bring home. 

Damien loves to be active, but also seems to express fatigue when he has done relatively little. He says he’d like to get more exercise and have a healthier life style but does not seem to be able to really put together a plan for this. He doesn’t get any regular exercise now.  He has been noted to enjoy the outdoors, his church community and basketball.   

Damien lives with his girlfriend and their 4 year old son in a 3^rd floor walk –up apartment in Bay Ridge Brooklyn.  He says he can walk up the stairs without being uncomfortable except when his feet are bothering him when he has a gout flare up.  He notes that he does get winded sometimes if he has to carry heavy groceries or his son’s tricycle up the stairs.

Other Information:

BP 140/88        P 72     R 18     T 98.6

Hgt 5 ft 10 in                Wgt 200 lbs                 Waist circumference: 43 in: inc

Gout: last episode of Right 1^st toe pain was 6 months ago after having a lobster dinner with red wine and a cheese appetizer.  He was given corticosteroids at an urgent care center and returned to baseline. 

Regular meds (when he takes them): hydrochlorthiazide 25 mg daily, diltiazem 120mg daily, allopurinol 100 mg daily

Case Study: Damien Jackson                                                           

Immunizations

• Influenza
• Tdap
• MMR
• Varicella 2 doses

Screening

Based on USPSTF recommendations:

• Alcohol misuse
• Depression
• Hypertension
• Obesity/weight loss
• HIV infection
• Hepatitis C virus infection

Because patient has hypertension, need to screen for:

• Diabetes mellitus
• Lipid disorders

Health Promotion/Disease Prevention Concerns

Injury Prevention:

Traffic safety

Falls prevention

Safe sleep environment

Poisoning prevention

Sports safety

Diet:

Damien is diagnosed with hypertension and gout, and has not been taking his medication regularly until now. His waist circumference is 43 inches. Given all these information, he is at increased risk of developing type 2 diabetes and coronary artery disease. He has a few dietary issues, such as drinking a lot of full fact milk, eating a large amount of meat, drinking sugary drinks, having sugary snack food.

One of the goal is to lower his risk of developing type 2 diabetes and coronary artery disease, one of the important dietary modifications is to cut down on sugar intake.

• Replace unhealthy snack food with small serving of nuts and seeds
• Begin with splitting the cake into two portions, and only eat half of the original serving size each time. Later on, slowly replace sweet treats with fresh fruits.
• Get a blender and make smoothies with fruits and vegetables to slowly replace sugary drink.
• Encourage patient to prepare these healthy food for his girlfriend and son might help him stick to the plan because he is also making healthy choice for his family at the same time

Hypertension is a risk factor for lipid disorder, so another thing is to cut down on fat. Also avoid food that would cause gout attack.

• Drink fat-free milk instead of whole fat milk. Other alternatives are plant-based milk such as soymilk, oatmilk or almond milk.
• Add more of vegetables in daily meal (salad and edmame).
• Bring homemade lunch to work as much as he can.
• Replace red meat with lean meat and fish for at least 2 meals every week
• Avoid lobster/shellfish and organ meats to prevent gout attack
• Besides these, Damien should watch his salt intake since he has hypertension.

Exercise:

Stick to a healthy diet is hopefully going to reduce the gout flare up, so Damien will have less limitation on doing exercise. Goal of exercise is to help him loss and maintain a healthier weight, also to lower his risk of developing cardiovascular disease. He is off to a good start by having the motivation to be active and do exercise. He would be standing and walking more during his new job, but its not adequate. CDC guidelines for adults are to have aerobic activity for 150min/week that’s moderate to intense or 75min/week that’s vigorous to intense. And muscle strengthening more than 2 times a week involving all major muscle groups.

He can start by doing light exercises and slowly increases intensity once he develops better tolerance and experience less fatigue. My suggestions are:

• Riding bicycles (can be with his son) for 30 minutes 3 x per week to start with, can increase duration or frequency later on
• Take 20-30 minutes walk after dinner on the days that he is tired or doesn’t feel like riding bicycles
• Incorporate strength training in small intervals (10-15 minuets) throughout week. At least 2 intervals to start with. Damien can utility light weights or resistant bands, or download an “exercise app” and follow their videos and suggestions
• Since he enjoys outdoor, hiking at least once every month with his family would be a great plan for weekends
• Play basketball at least once a month to start with

Harm Reduction:

• Quit cigar or replace cigar with smokeless nicotine alternatives
• Encourage regular follow up since he has health insurance now

Brief Intervention:

Smoking cessation

Damien reports that he smokes about 4 cigars a week with his friend at a cigar bar. Based on the information, he didn’t express any motivation to make change on this habit.

1) I would start by accessing his readiness to change and ask for permission:           

• I think quitting smoking is very important for you because it would further decrease your risk of having heart disease. Can we talk about this some more?
  • Have you ever tried to cut back on or quit smoking?

2) If he would like, I will continue to give information on the harm and benefit about smoking and quitting. Also give advise on medications and other tools that can help he quit cigar

• Ex) smoking cigar takes much longer time and can get more nicotine than cigarette
• Ex) quitting can improve exercise tolerance and save money

3) Assess addition to nicotine and if there is any other motivating factors that would help him stop smoking

4) Discuss and design a plan for he to start quitting

5) Schedule follow up appointments

Mrs. Williams, 55 y/o female with 5 years of Type 2 DM and 20 years of HTN. Never smoked, drank alcohol, or used drugs. She weights 200 lbs with a BMI of 38. Her blood sugar is higher than the target value for the pass 3 months. Her blood pressure is well controlled on medication. Her total cholesterol is 240 and her HDL is 40. Her physician recommended on taking statin but she doesn’t want to because she heard bad things about statin drugs. Her goals are to loss weight, to better manage her glucose and cholesterol level.

Mrs. Williams realizes she needs to make changes and live a healthier life after knowing her sister just had a heart attack. She enjoys cooking but don’t have a lot of time to cook. She can walk on level ground and up one flight of subway stairs. Experienced shortness of breath if there is more than one flight. As a kid she enjoyed riding her bike and she liked to dance when she was young.

Nutritional Rx:

• Only getting sugar-free coffee from the cart outside the office and replace donut with less sugary options, such as whole-wheat bread
• On weekends, replace bacon with fresh fruits such as apple slices or berries. Avoid syrups
• Do meal-prep on weekends or on days when you have more free time. Use olive, canola, soybean or corn oil when cooking at home. Try to bring lunch to work as much as possible
• Instead of getting pizza or McDonalds, look for healthier options around work for lunch.
• Get salad kits from supermarket and use low-fat dressing
• Getting chicken from the market is a good choice of protein. Try to get some fish or lean cut meat next time. When choosing sides, get beans or vegetables and avoid starchy vegetables like potatoes
• Cut down on snacking in the afternoon gradually. Eating cookies or chocolate bar no more than twice a week to start with. Try fresh fruit, low fat yogurt or nuts for snack

Exercise Rx:

• Riding bike or playing soft ball with grandchildren on weekends or during the evening as much as you can
• Taking light walks to begin with. Try to walk for 15 minutes after dinner at least 3 times a week. On the days when you have cookies for snake, try to walk a little longer (20-30 minutes)
• Sign up for dance class with a friend and encourage Mr. Williams to join
• Follow up with the patient 3 month later to check for blood sugar and cholesterol level and weight loss