Identifying Data:

Age: 43

Sex: female

Date of encounter: November 21^st, 2022

Location: Centers Urgent Care Middle Village

Race: White

Source of Information: Self and sister

Reliability: Reliable

Source of Referral: Self

 

Chief Complaint: Mouth pain x 5 hours

 

History of Present Illness:

Pt is a 43 y/o female with PMHx of type 2 DM, presenting to urgent care clinic for mouth pain since waking up about 5 hours ago. Pain is located under the tongue and extends to her jaw, constant and worsening, characterized as dull, of 6/10 severity, without exacerbating factors, and mildly improved with ibuprofen 600mg. Pt also complains of chills, difficulty swallowing, along with swelling of the submandibular area and of the bottom of the inside of her mouth. Sister notes a change in the pt’s voice as well. Patient mentions having right sided tooth pain for the last 2 days since her root canal procedure on one of her molar teeth, for which she was advised by her dentist to take Tylenol or ibuprofen. She states she was not given antibiotics after the procedure. Patient denies new medications, foods, or other exposures. She denies fever, trismus, ear pain, drooling, SOB, throat pain, rash, cough, nasal congestion, chest pain, vomiting, weakness.

 

Past Medical History:

Diabetes mellitus, type 2

Immunizations – up to date

 

Past Surgical History:
None

 

Medications:

Metformin 500mg tablet twice daily PO

 

Allergies:

Denies any drug, environmental, or food allergies.

 

Family History:

Mother, 68 y/o, alive and well – DM2

 

Social History:

Habits –Denies smoking history. Denies alcohol use. Denies history of illicit substance use.

Travel – No recent travel.

 

Review of Systems:

General – (+)chills. Denies recent fever, weight loss/gain, fatigue, night sweats, or change in appetite.

Skin/nails – Denies rash, erythema, change in pigmentation.

Head – Denies headache, dizziness, lightheadedness, head trauma.

Eyes – Denies visual disturbances..

Ears – Denies change in hearing, otalgia. No hearing aid use.

Nose – Denies congestion.

Mouth/throat – (+)swelling, difficulty swallowing. No tongue pain or swelling.

Neck –. (+)swelling, pain. Denies stiffness, lumps, injury/trauma.

Pulmonary – Denies SOB, DOE, cough, hemoptysis.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling.

GI – Denies abdominal pain, vomiting, diarrhea, constipation.

Genitourinary – Denies dysuria, hematuria, frequency.

Nervous – Denies confusion, weakness, numbness.

Musculoskeletal – Denies body aches, joint pain.

 

 

Physical Exam:

Vital signs:      BP: Seated, R-arm: 136/83

RR:      17 breaths/min, unlabored

Pulse: 89  bpm, regular

T:        100.8 degrees F (oral)

O2 Sat: 98% on room air

Height: 5 ft 7 inches        Weight: 172 lbs.       BMI: 26.9

 

General: Pt alert, oriented. No acute distress. Well nourished. Looks stated age.

Skin: Skin is warm & moist. No ecchymosis. Nonicteric, no other lesions noted, no tattoos. No rashes appreciated.

Hair: well distributed

Nails:  no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic.

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. Mild amount of cerumen in auditory canals bilaterally. No discharge or other foreign bodies in external auditory canals.  Right and left TM pearly white and fully intact with cone of light in good position.

Nose –Symmetrical. No masses, lesions, deformities, trauma, discharge. Nasal mucosa pink & well hydrated.

No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection, perforation.

No foreign bodies.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars. Tongue is midline but slightly elevated. No tongue masses or lesions. Uvula is midline and rises symmetrically with phonation.

Oropharynx is pink and moist. Poor oral hygiene. Tonsils are obscured by tongue. Floor of oral cavity is elevated and tender to palpation. No erythema.

Neck – (+)swelling to submandibular region with mildly increased warm and tenderness, without erythema, without crepitus. Full ROM.  No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRL. EOMs intact with no significant nystagmus.

Chest/Pulmonary: Chest is symmetric, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No stridor. Airway is patent, patient is speaking comfortably in full sentences. No use of accessory muscles noted. Lungs CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated.

Abdomen: Abdomen nondistended, symmetric.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner. Speech and language – follows 2 stage commands. Speech is of appropriate quantity, rate, volume, flow, and articulation. Conversation progresses logically towards a goal. Oriented to name, date, time, location.

Neurologic: Cranial Nerves –See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. No ptosis. Symmetric and fluid facial movements. No difficulty with BMP or LTND speech sounds. Soft palate rises and uvula remains midline. (+)muffled, “hot potato” voice. No facial droop.

Peripheral Neuro –

Motor/Cerebellar: Full active ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Gait steady with no ataxia.

Meningeal Signs: No nuchal rigidity noted.

Musculoskeletal: No edema / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities.

 

 

 

Differential Diagnoses:

• Ludwig’s angina
• Dental abscess – although no obvious abscess seen on exam
• Gingivitis, severe
• Angioedema – less likely given no new exposures or known allergies, but considered given presentation and recent NSAID use.

Assessment:  43 y/o female with PMHx of DM2, and root canal procedure 2 days ago, presenting with 5 hours of fever, pain and swelling to the floor of the mouth, difficulty swallowing, muffled voice, and swelling and tenderness to submandibular space.

 

Plan: Given concern for Ludwig’s angina, patient was strongly advised to be picked up from urgent care via ambulance and immediately transported to the ED for airway monitoring and possible IV antibiotics.

Despite at-length discussion on the risk of airway compromise with the patient, she refused ambulance and stated her sister will take her to the ED. Pt signed AMA form and left urgent care.