Identifying Data: 

Full Name: C.Q 

Address: Manhasset, New York 

Date of Birth: XX/XX/XXXX

Date & Time: November 18, 2024 | 10AM 

Location: North Shore University Hospital 

Religion: Christian 

Source of Information: Self  

Reliability: Reliable 

Mode of Transport: Self 

 

Chief Complaint: “left arm swelling” x 1 day 

 

History of Present Illness:  

Patient is a 30-year-old male with a past medical history of gout, presenting due to left arm swelling for one day. Patient states he has had some left upper lip swelling as well for the past day. Left arm swelling started at approximately 4PM yesterday and has progressed from only being swollen from the left hand up to the wrist, and now up to the forearm to the elbow. Patient endorses mild joint pain and stiffness, particularly in his 1st and 2nd digits on the left hand. Tried to take Indomethacin which he was previously prescribed for gout without any relief. Says it is not painful but was concerned with how much it was swelling and how it progressed up the arm.

 

Reports a recent trip to Florida which he drove but stopped frequently during the drive. States he was helping his uncle move items out of a water damaged house. Arm was not submerged but in contact with wet items and was frequently lifting heavy boxes. Denies any open wounds or bug bites. He returned to NY the same day that the swelling began. He is an avid rock climber and is concerned with returning to his previous activities. Patient denies any recent trauma to the arm or open wounds.  Denies fever, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, weakness, inability to move the arms or legs, numbness, tingling. Denies any new foods, medications, detergents, irritants. No history of similar episodes in the past.  

 

Past Medical History:  

Gout 

 

Prior Hospitalizations:  None 

 

Childhood Illnesses: None  

 

Immunizations: Fully up to date, COVID (2021), Influenza (2024) 

 

Screening Tests: Dental – January 2024 

 

Past Surgical History:   

None  

 

Medications:  

Indomethacin, 50 mg oral capsule 3 times a day, PRN for gout 

 

Ancillary physicians: 

PCP: North Shore University Hospital – Primary Care 

Phone: (516) 622-5070 

 

Allergies:  

No known drug, food or environmental allergies.  

 

Family History: 

Non contributory – pt reports both parents are alive and healthy with no chronic conditions. No known family history of malignancy or cardiac disease. 

 

Social History: 

Mr. CQ is a 30-year-old, pleasant, unmarried male, who lives in a house with his parents. He is a contractor and avid rock climber. He has adequate support from his parents and girlfriend who is at bedside with him. 

 

Habits: Denies alcohol consumption. Denies history of illicit substance use. Denies smoking/marijuana use. Endorses caffeine intake – 8 oz of coffee/day.  

Travel: Reports recent travel to Florida by car.  

Diet: Pt admits to having a well-balanced diet.  

Exercise: Pt reports 60-90 minutes of exercise/physical activity daily. 

Sleep: 6-7 hours a night with no difficulty.  

Safety Measures: Admits to wearing a seatbelt in moving vehicles.  

Sexual History: Pt is currently sexually active with one female partner x 5 years. 

Proxy: None 

Code Status: Full code 

Advance Directive: none  

 

Review of Systems:  

General – Denies loss of appetite, fatigue, fever, recent weight gain or loss, malaise, chills or night sweats. 

Skin, hair, nails – +swelling and mild erythema of left hand extending to left elbow. Denies rash, pruritus, excessive sweating, hair changes. No clubbing, cyanosis, paronychia.  

Head – Denies headache, dizziness, denies head trauma, fainting. 

Eyes – Denies visual changes, discharge, and photophobia.  

Ears – Denies loss of hearing, ear infection, ear pain, ear drainage, tinnitus or use of hearing aids.  

Nose/Sinuses – Denies nasal congestion, epistaxis, discharge, swelling.   

Mouth/Throat – Denies sore throat, cough, bleeding gums, hoarseness.  

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

Breasts – Denies skin changes, lumps, nipple discharge, pain.   

Pulmonary System – Denies SOB, cough, DOE, hemoptysis or cyanosis.  

Cardiovascular System –  Denies chest pain, irregular rhythm, palpitations, edema of the legs, syncope.  

Gastrointestinal System – Denies nausea, vomiting, decreased oral intake, intolerance to specific foods, hemorrhoids, constipation, or diarrhea.  

Genitourinary System – Denies urinary incontinence, frequency, dysuria.  

Nervous – Denies dizziness, gait disturbances, sensory disturbances, paresthesia, or changes in cognition/mental status.  

Musculoskeletal system – +joint stiffness to 1st and 2nd digit of left hand. Denies muscle soreness, bone deformity. 

Peripheral vascular system – Denies edema and erythema of the lower extremities, hx of blood clots, varicose veins. 

Hematological System – Denies easy bruising, lymph node enlargement, anemia, blood transfusions. 

Endocrine system – Denies hirsutism, excessive sweating, heat intolerance, excessive hunger/thirst.  

Psychiatric – Denies changes in mood, suicidal ideations, and changes in eating habits. Denies irritability.  

 

Physical Exam:  

 

General: 30 year old male, appears as his stated age. Well-groomed male with proper posture and appropriately dressed for the weather. Awake, alert, and oriented to person, place, time and situation. 

 

Vital Signs: 

BP: 118/71 Seated; (L) 

HR: 77 BPM, regular rate & rhythm  

RR: 18 breaths/min, unlabored  

Temperature: 36.7°C, Oral  

SpO2: 98% Room Air  

Height: 170.2 cm 

Weight: 87.7 kg  

BMI: 30.3 kg/m2 

 

Heart: 

Regular rate, rhythm, and amp. Distinct S1/S2 with no murmurs, splitting of S2, friction rubs, or S3/S4 appreciated.  

 

Thorax/Lungs: 

Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored. Non-tender to palpation throughout. CTAB. No stridor. 

 

Abdomen:  

Abdomen is soft, symmetrical and non-distended. +BS in all four quadrants. Non tender to palpation. No guarding, no rebound. 

 

HEENT: 

EOMI. Lip swelling to the upper lip on the left side. No erythema or crusting of the upper lip. No noted lesions, bruising, or lacerations. No tonsillar exudates, nasal discharge, mucous membranes moist. No tongue swelling. 

 

MSK: 

Left forearm compartment soft but swelling and erythema to the left upper extremity extending from all fingers to the elbow anteriorly. NTTP. No obvious infected open wounds. No crepitus. Left UE has full, painless AROM.  No LE edema. 

 

Peripheral Vascular: No clubbing, cyanosis, or edema to LE noted. Carotid pulses are 2+ bilaterally, no bruits present.  

 

Neurological: symmetric face, normal speech, 5/5 strength in all 4 extremities. Median, ulnar, radial nerve intact with full spontaneous range of motion for all fingers in both hands.  

 

Differential Diagnoses:  

• Cellulitis 

• Angioedema 

• Acute gout flare 

• Compartment syndrome 

 

Workup: 

• CBC, CMP, ESR, CRP 

• CT upper extremity, LUE US 

• CT of the left lower extremity demonstrates soft tissue edema at the elbow posteriorly and volar side of the wrist. No abscess. No tracking gas. No suspicious osseous lesion. 

• POCUS ED: no evidence of proximal deep vein thrombosis in the left upper extremity. 

 

CBC w/ AutoDiff 

WBC	7.16
RBC	5.26
HGB	15.1
HCT	45.2
MCV	85.9
MCH	28.7
MCHC	33.4
RDW	12.2
PLT	304
Neutrophil %	67.5
Lymphocyte %	25.1
Monocyte %	6.1
Eosinophil %	0.7
Basophil %	0.3

 

CMP 

Glucose	93
BUN	16
Creatinine	0.94
Calcium	9.8
Sodium	137
Potassium	4.8
Chloride	100
CO2	23
Albumin	4.8
Bilirubin Total	0.6
Alk Phos	77
AST/SGOT	25
ALT/SGPT	112

eGFR: 112 

CRP: <3 

ESR: 9  

Cr Kinase: 134  

PT: 11.5 

INR: 1.00 

aPTT: 31.0 

Blood Type: B+ 

 

Assessment:  

30-year-old male with a history of gout presents with 1 day of left upper extremity swelling and erythema, with associated angioedema on the left side of the upper lip. POCUS in ED ruled out DVT. In ED patient received Zosyn 3.375 g in dextrose 5% 100 mL, IV intermittent once infused over 30 minutes & Clindamycin 600 mg in dextrose 5% 50 mL, IV intermittent once infused over 30 minutes x 1 dose, Methylprednisolone injectable 125 mg IV push, once. Patient also received 1 dose of Benadryl in the ED for angioedema. Admitted to medicine for further monitoring with ID on board. Will assess CT upper extremity to evaluate for deep space infection and follow up labs.  

 

Plan:  

#left arm swelling and erythema 

• ID consult: recommended Cefazolin IVPB 1000 mg q8h, suspicion for cellulitis low, more likely to be allergic reaction – finish with Cephalexin 500 mg q6h & short course of oral steroids with taper  

 

#angioedema 

• Benadryl 50 mg IV push received in ED – swelling resolved. 

 

#Diet 

• Regular diet  

 

#Activity 

• Can resume normal activities at d/c once swelling and erythema resolve. 

 

#Disposition 

• d/c on short course of oral steroids with taper 
• Follow up with allergy clinic outpatient