H&P #1

Identifying Data

Full Name: L. R.

Sex: Female

DOB: xx/xx/1990

Date & Time: August 30, 2023 10:00 am

Location: New York Presbyterian Queens

Religion: Catholic

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Uber

 

Chief Complaint: “left breast pain” x 3 days

 

History of Present Illness:

32 y/o F with past surgical hx of B/L breast augmentation in 2016 presents to the ED c/o LT breast pain s/p mechanical fall 3 days ago. As per patient, she was in the shower when she accidentally slipped and fell, hitting her left breast against a handle bar. States pain worsened yesterday and was accompanied by fever with a Tmax 101.6 F. Rates pain a 7/10 in severity and states pain does not radiate. Pain is temporarily relieved with OTC Tylenol. Reports worsening erythema and tenderness of breast over past several days. Patient admits to nausea and 1 episode of NBNB vomiting yesterday. Patient expresses concern of ruptured breast implant. Denies head trauma, LOC, chest pain, cough, SOB, sore throat, diarrhea, nipple discharge/drainage, or sick contacts.

LMP: 8/19/23; patient is not currently breast feeding

 

Differential diagnosis:

  1. Cellulitis
  2. Mastitis
  3. Breast implant rupture
  4. Breast abscess

 

Past Medical History

Medical History:

  • No past medical history
  • No past hospitalizations or history of blood transfusions.

Medications:

  • No prescription medication use.
  • Denies herbal supplement use.

Surgical History:

  • B/L breast augmentation, completed in Colombia in 2016; no records; no known complications

Allergies:

  • No known drug/food/environmental allergies

Family History:

  • Mother: Age 57, alive and well. PMHx HTN, T2DM, HLD.
  • Father: Age 56, alive and well. PMHx HTN, HLD.
  • 1 daughter, age 2, alive and well
  • Maternal aunt: Hx breast cancer, dx age 68
  • Maternal grandparents: unknown medical hx
  • Paternal grandparents: unknown medical hx

Social History:

  • Smoking: Never
  • Alcohol: Socially, 1-2 drinks at social outings
  • Denies past or current illicit drug use
  • Marital History: Single
  • Language: Patient requires Spanish translation, able to read and write
  • Education: High school graduate
  • Occupational History: Home health aide
  • Travel: No recent travel
  • Home situation: Lives in Queens apt with boyfriend and daughter. 2nd floor walk up.
  • Sleep: Patient states she sleeps about 6-7 hours per night
  • Exercise: Denies regular exercising
  • Diet: rice & beans and protein; few vegetables & fruit
  • Caffeine: 1 cup of coffee daily with milk and sugar.

 

ROS:

  • General: Admits to fever. Denies fatigue, chills, night sweats, weight loss, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums. Patient states last dental visit was about 8 months ago.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: See HPI
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: Admits to nausea and vomiting. Denies abdominal pain, diarrhea, constipation.
  • Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, coldness of extremities, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 197 lb Height: 65 inches       BMI: 32.98 kg/m2
  • BP: 104/62, right arm sitting
  • RR: 18, unlabored
  • HR: 70, regular
  • Temp: 99.6 F oral
  • SpO2: 97% room air

General: 32-year-old overweight female who appears stated age. A/O x 3 and appears in no acute distress, laying comfortably in bed.

HEENT: Normocephalic & atraumatic; PERRL; EOM intact; nares patent B/L; Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Breast: Left breast area of localized and sharply demarcated erythema and tenderness. Warm to touch. No drainage, no induration or area of fluctuance. Well healed surgical scar. Intact breast implants B/L.

Abdominal: Abdomen symmetric and non-distended, with no scars. Normoactive bowel sounds in all 4 quadrants. Non-tender to palpation and tympanic throughout with no guarding or rebound.

Musculoskeletal: FROM, no cyanosis, no peripheral edema

 

Labs:

CMP w/ diff

WBC 14.82
RBC 4.35
HGC 11.9
Crit 37.2
MCV 85.5
MDH 27.4
MDHC 32.0
RDW 13.0
PLT 295
MPV 11.4
NEUTP 78.9
LYMPHP 14.20
MONOP 6.2
EOSP 0.20
BASOP 0.20
NEUT 11.69
LYMPH 2.10
MONO 0.92
EOS 0.3
BASO 0.3

BMP

NA 135
K 3.9
CL 100
CO2 24
BUN 10.9
Creatinine 0.74
GLU 85
Anion gap 11
CA 9.4

LFTs

TP 7.3
ALB 4.4
GLOB 2.9
TBILI 0.8
DBILI 0.2
IBILI 0.6
SGOT 23
SGPT 34
ALK 113

HCG: negative

UA: negative

Blood cultures x 2: pending

 

Imaging:
CT chest without IV contrast

Impression: Contusion of left breast with associated cutaneous thickening and subcutaneous edema. Grossly intact appearing bilateral breast implants. Minimal fluid/edema surround the left implant. No acute fracture identified. No lung contusion or consolidation. No pleural effusion or pneumothorax.

EKG: normal sinus rhythm

 

Assessment/Plan:

32 y/o F w/ hx B/L breast implants (Columbia 2016) presenting with left breast erythema and pain. States she fell 3 days prior to presentation in bathroom, hitting her left breast on a handle bar. Vital signs stable. Labs significant for WBC 15. Imaging reveals contusion to left breast w/ skin thickening and subcutaneous edema with intact implants.

#Left breast cellulitis

  • Patien given CTX 1gm x once and Vanco 1250gm IV x once in ED; Continue IV abx for cellulitis (CTX 1 gm IV daily) pending recommendations
  • Consult ID for abx recommendations
  • General surgery consulted in ED, no acute surgical intervention
  • Follow up with plastics
  • F/u blood cultures x 2 and procalcitonin
  • Monitor CBC (trend WBC), cmp, fever curve
  • Tylenol 650 mg prn for pain

#Nausea

  • Zofran 4mg IV PRN

Diet: regular diet

GI ppx: protonix PO daily

DVT ppx: lovenox

Code status: full

 

Patient Education:

  • Cellulitis is a type of bacterial skin infection that can cause redness, swelling and pain in the infected area. The bacterial infection typically occurs after a break in the skin.
  • Cellulitis is treatable with antibiotics, however compliance with medications is very important. When you are transitioned to oral antibiotics, it is important to finish the entire course of antibiotics.
  • The local swelling and redness should begin to improve 2-3 days after starting antibiotics, however symptoms may continue for up to 2 weeks
  • Wound care:
    • Wash the area with clean water 2 times per day
    • Keep the area dry – pat the area dry with a clean towel after cleaning
    • Do not apply any products to the area
    • Cellulitis is typically not contagious – however wash hands before and after touching the infected area.
  • Prevention:
    • In the future if you get a scrape, cut, etc wash the wound with clean water ASAP
  • Home instructions:
    • Upon discharge, complete full course of antibiotics
    • Please return to the ER if you experience:
      • Worsening fever or return of fever
      • If the area becomes more swollen, red or tender
    • Home safety:
      • In the shower it Is important to have non-slip shower mats to help prevent falls