IM H&P 1

Chief Complaint
“Facial swelling” x 2 days

History of Present Illness
57-year-old male with a past medical history of hypertension and DM2 who presented to the ED with facial swelling x 2 days . The patient reports that approximately 1-2 weeks ago, he experienced flu-like symptoms. Symptoms include runny nose and nasal congestion causing him to frequently rub his nose. Two nights ago, he noted mild swelling and pain around his nose, which progressively increased to involve his face and head. Last night, he developed fevers, one episode of non-bloody, non-bilious emesis, and multiple episodes of diarrhea, prompting his visit to the ED. This morning, he states that his fever and vomiting have resolved, although he had one episode of diarrhea. Pt denies current nausea, chest pain, shortness of breath, abdominal pain, dysuria, hematochezia, or melena.

In the ED he was given vancomycin 1g, zofran 4mg, Maalox 30ml, pepcid 20 mg, LR 1 L, toradol 15 mg..

On HD 3, the patient reports that he is overall feeling much better, with significant improvement in his facial swelling and general condition. He still experiences slight discomfort in his nasal area, particularly around the site of the previous swelling.

Past Medical History

  • Hypertension, well controlled on medication
  • Type 2 Diabetes Mellitus, managed with metformin

Medications

  • Lisinopril 20 mg daily
  • Norvasc 5 mg tablet
  • Metformin 1000 mg BID
  • Tylenol 325 mg

Surgical History

  • Denies any previous surgical history 

Allergies

  • No known drug, food, or environmental allergies.

Family History

  • Mother: Age 80, alive and well; PMHx of hypertension
  • Father: Age 82, alive and well; PMHx of T2DM

Social History

  • Smoking: Currently smokes cigarettes for 10 years (10 pack-year history).
  • Alcohol: Socially, 1-2 drinks per week.
  • Illicit Drug Use: Denies.
  • Marital Status: Married, lives with wife and two children.
  • Occupation: Construction worker.
  • Travel: No recent travel.
  • Exercise: Occasionally walks for exercise, about 2-3 times per week.
  • Diet: Primarily home-cooked meals.

Review of Systems

  • General: Denies fever, denies chills, night sweats, weight loss.
  • Skin: Reports facial swelling/discomfort over nasal region.
  • HEENT: Denies headache, visual disturbances, or ear pain.
  • Neck: Denies swelling or stiffness.
  • Pulmonary: Denies cough, dyspnea, wheezing.
  • Cardiovascular: Denies chest pain, edema, palpitations.
  • Gastrointestinal: Denies abdominal pain, reports diarrhea.
  • Genitourinary: Denies dysuria or changes in urinary habits.
  • Musculoskeletal: Denies muscle or joint pain.
  • Nervous System: Denies weakness or changes in cognition.
  • Peripheral Vascular: Denies coldness of extremities or swelling.
  • Hematologic: Denies easy bruising or bleeding.
  • Endocrine: Denies excessive thirst or hunger.
  • Psychiatric: Denies depression or anxiety.

Physical Exam

  • Vital Signs:
    • BP: 132/80
    • HR: 80
    • RR: 15
    • Temp: 37.5°C
    • O2 Saturation: 100% on room air
  • General: 57-year-old male who appears in mild discomfort due to facial swelling.
  • HEENT: Facial swelling noted, particularly around the nasal area,tender to palpation . No conjunctival injection, nasal discharge, or oral lesions observed.
  • Neck: No lymphadenopathy; neck supple.
  • Heart: Regular rate and rhythm; no murmurs.
  • Lungs: Clear to auscultation bilaterally; no wheezes or crackles.
  • Abdomen: Soft, non-tender, no distension.
  • Skin: Warm to touch over the swollen areas; no rash or other lesions noted.

Labs/Imaging

  • Laboratory Results:
  • Imaging:CT Maxillofacial with IV contrast
    • CT shows a 1.6 × 1.2 cm low-attenuation abnormality related to nasal soft tissues, compatible with stated clinical assessment of facial cellulitis with abscess formation.

DDX:

  • Facial Cellulitis 
  • Erysipelas 
  • Sinusitis with complication 
  • Periorbital cellulitis 
  • Trauma 

Assessment and Plan

A 57-year-old male with a past medical history of hypertension and diabetes mellitus who presented to the ED with progressive facial swelling, initially localized to the nasal area and subsequently involving the entire face and head. His symptoms were accompanied by fever, vomiting, and diarrhea. He was initiated on Vancomycin and Zosyn for suspected facial cellulitis with associated abscess formation which was confirmed with CT . Since admission, he has experienced significant clinical improvement, with only mild residual discomfort in the nasal area. His WBC count has decreased from 15.70, indicating a favorable response to antibiotic therapy, and his lactic acid level is stable at 1.1. 

  1. Sepsis likely secondary to facial cellulitis and nasal abscess
    • Continue with Vanco and Zosyn, check Vanco level before 4th dose(12-15 goal).
    • Blood culture NGTD 10/05
    • ENT consult(Attempted needle aspiration at bedside with minimal purulent drainage)
      1. Follow up outpatient at NYPQ ENT clinic in 1-2 weeks. 
    • Pain control as needed(acetaminophen 325MG PRN)
  2. Hypertension
    • C/W Lisinopril and Norvasc.
    • Monitor blood pressure and adjust dosages accordingly.
  3. Type 2 Diabetes Mellitus
    • Optimize current metformin regimen; consider dietary counseling.
  4. Active smoker
    • Nicotine patch for smoking cessation.
  5. VTE Prophylaxis
    • Lovenox SQ as prophylaxis.

Patient Education:

Facial Cellulitis with Nasal Abscess

Cellulitis is a bacterial skin infection causing redness, swelling, and pain. In your case, it led to significant facial swelling and an abscess near your nose. You’ve been on antibiotics (Vancomycin and Zosyn) for three days with noticeable improvement. An ENT specialist attempted to drain the abscess, but minimal fluid was obtained. We’ll continue monitoring your progress, and you’ll follow up with ENT after discharge.

As you complete the antibiotics, the facial swelling should keep improving, though full recovery may take 1-2 weeks. It’s important to finish the entire course to fully clear the infection.

Wound Care:

  • Clean the area twice daily with water.
  • Pat dry, avoiding scrubbing or irritation.

Prevention:

  • Wash cuts/scrapes immediately and monitor for swelling or redness. Seek help if needed.

When to Return:

  • Fever returns or worsens.
  • Increased redness, swelling, or tenderness.
  • Difficulty breathing or spreading swelling.