Facial Swelling Case Study for Nurse Practitioners
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Show notes:
I had a patient last week who came in with facial swelling. It’s not a super common chief complaint in primary care, honestly, and neither were her exact symptoms or presentation.
The whole situation brought me back to my new NP roots —
When I first talked to this patient, I had no idea what to do!
That feeling used to be 👏 just 👏 so 👏 uncomfortable.
But one of the benefits to accumulating years of practice is that I’m so much more comfortable with not knowing the answer off the top of my head. I’ve learned how to navigate NOT knowing.
I’ve built a system that helps me figure out where to go when I don’t have the answers.
Instead of feeling stressed, panicked, or inadequate, I can be curious, intrigued, EXCITED to find the answer for my patient —
I want this for you, too.
There is ALWAYS something new to learn in medicine, every day.
(That’s what’s so fun about it!!)
But let’s get to the good stuff.
What makes this particular case study useful is that it provides a PERFECT opportunity to walk through healthcare problem solving together. We talk about facial swelling, but we also look at:
How to approach situations when you don't know what to do with a patient's chief complaint
Questions you can ask for a better patient history
Evaluating potential differential diagnoses
And what the triggers are for seeking specialist support
Update on this case (spoiler alert):
Unfortunately, this patient was lost to follow-up. Her labs came back overall normal so I referred her to allergy as well as rheumatology but didn't hear back from the patient or consults! Such a bummer!
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0:00
well hey there it's liz rohr from real
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world np
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you are watching np practice made simple
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the weekly videos to help save you time
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frustration
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and help you learn faster so you can
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take the best care of your patients
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in this week's episode i want to talk
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about a case study of a patient that i
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saw the other day
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and the reason i'm talking about it it's
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not the most common
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diagnosis or chief complaint to see in
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primary care but what i really loved
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about it is how
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it really brought me back to my like new
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nurse practitioner roots
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of of basically the situation of like i
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don't actually know what to do here
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and when i was in new grad i felt like
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that kind of all the time
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so on the one hand it's an interesting
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case with an interesting workup
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that's still underway but i will report
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back in the comments below when i have
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the results and the outcome of what
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happened
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but also um kind of highlights how to
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approach a situation where
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you're not quite sure what to do with
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the chief complaint that is sitting in
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front of you
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in the room so um without further ado
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i'm going to share my screen with you
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and i'm going to talk about a patient
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with facial swelling so i hope you enjoy
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okay so this is the case study about the
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woman with facial swelling so this is
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maria this is
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if you're watching versus listening this
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is not her real name or her photo
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she was a 34 year old female that came
Patient Background Information
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in to see me the other day
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and her chief complaint was for facial
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swelling
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so she noticed facial swelling about a
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month ago
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when i asked her about her symptoms she
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said sometimes it's better in the
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morning
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and then gets worse throughout the day
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but it's really different each day
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sometimes it's the same all the time
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sometimes it's better in the morning
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she doesn't have any itching pain
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redness
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and the symptoms aren't worsening at all
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they've just been the same for the last
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month
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her mother also noticed that her cheeks
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were
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you know more swollen looking than they
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were before
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she hasn't done any treatment for it in
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terms of like ointments or medications
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or anything like that
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and as far as she knows there was
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nothing that started the symptoms
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a month ago it just she just happened to
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to
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kind of more or less gradually notice it
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happening
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she's never had it happen before and if
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you listen to any other
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or listen to or watch any of the other
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episodes you'll know that
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this is a really key question that i
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always recommend
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asking when it comes to the history
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because a lot of patients will forget to
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volunteer that information
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that they've actually had this before
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they've had this whole treatment
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because a lot of patients assume that we
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have records for basically everything
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that's ever happened to them and that is
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not always the case
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unfortunately and then she was wondering
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if it was she's done her own research
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but she's also been wondering if it's
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body weight related and so she was has
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been going to the gym regularly
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she drinks adequate amounts of water and
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stays hydrated she's eating a healthy
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diet she's been trying to lose weight
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and it doesn't seem to impact her facial
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swelling
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at all so for past medical history she
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has a bmi of 33.
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she has one child one pregnancy and one
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life child who's four years old
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otherwise she has no other medical
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issues that she knows about
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she doesn't have any past surgical
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history or family history
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aside from a bmi that's greater than 30
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in her family members but she denies any
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history of these symptoms or cancers or
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any of the kind of like major causes of
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death
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of her family you know a cvd cancer
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diabetes hypertension things like that
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so none of that that she knows of
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she does not take any medications or
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supplements and her blood pressure at
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the time of the visit was 122 over 78
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heart rate of 72 oxygen was normal at 80
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98 and then her bmi again was 33
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her last mental period was 25 days ago
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and she says that it's regular and it
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happens every 27 days on the dot
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she has one cis male partner and uses
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condoms for contraceptives because she's
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not interested in getting pregnant at
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this time
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and so that's the kind of background
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information and
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in presenting this case i want to
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my goal with presenting this case is is
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kind of presenting the real world
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situation
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because i think it's so i don't know
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it's such a hard transition to practice
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that you learn about all of these things
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in school
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and then you see real patients in front
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of you and
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one of the conundrums is that patients
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will come
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with a chief complaint of something and
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then when you get into the room it's
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potentially something else so in this
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case her chief complaint of facial
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swelling was actually facial swelling
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but before i get into the actual
History Questions
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physical exam part i just wanted to
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pause if you want to pause here you can
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think about other history questions that
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you want to ask but
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um i just want to say that like this
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this case i love because it really
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reminded me of when i was a new nurse
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practitioner and i felt like i didn't
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know anything
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when in fact i did but it's there's a
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lot of learning that you do
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as you go but this scenario of having a
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chief complaint that either you're not
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prepared for because it's different from
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what the patient has said what
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before you got into the room to the
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medical assistant or to the call center
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to the
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administrative staff who booked the
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appointment versus what you get when
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you're in the room that's always an
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opportunity or possibility because
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as much as we try to present to prepare
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ahead of time we can't always
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and so this is an example of a situation
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for me as an experienced
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nurse practitioner i was like i'm not
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quite sure what to do
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and so i just relied on those past ways
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that i've dealt with cases
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as a newer nurse practitioner and kind
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of defaulting to that pattern of like if
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i don't know what to do what is the
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system i have to use to support myself
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so first things first is old cart and
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i've talked about this before in other
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episodes but
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i recommend having some sort of
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systematic process of asking your
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history questions
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and the way i've presented it i've
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actually can i've actually covered all
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of those old cart
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um systems so old card is that acronym
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for history taking where it's onset
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location duration characteristics
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associated factors relieving factors and
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time
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so we're asking about when it started
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where it is if it comes and goes what
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the characteristics are what the
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treatments are
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things like that so if you don't know
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what you're doing if you don't feel like
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you know what you're doing or you're
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unprepared
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in that moment to handle facial swelling
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differential diagnosis
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always default to what your system is
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and i use old cart and i recommend doing
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that
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the other hack which i've talked about
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before as well is is
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asking the review of systems questions
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and honestly if you're not sure
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the hack is to just pick a system ask
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the whole thing
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and then you get to excuse yourself look
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some stuff up and then ask more
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questions if you've forgotten them but
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that's the again that kind of like
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safety default of like
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what can i do to get the most history
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most helpful situation for this patient
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in this moment
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right and then i also love the question
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is it getting worse
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better or staying the same again in that
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history presentation i just did
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i talked about all those things already
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but those are things to consider if you
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haven't already in your history taking
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and again have you had this happen
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before and then
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your history questions the further
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history questions you can ask
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will be based on your differential
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diagnosis and like i said if you're not
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sure what to do with a patient for that
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chief complaint you might not know what
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those differentials are off the top of
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your head and that is okay
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you have resources to consult go back
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and look at them
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and ask those questions but the hack way
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around that is to ask the old cart
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framework of questioning for history
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as well as choosing the ros that is
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specific to that chief complaint and
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then the other potentially associated
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reviews
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of systems the body systems that are
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potentially related and that's just to
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be really transparent i'm trying to be
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like a lot more candid
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as as candid as i can be on this channel
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about like what the real world is like
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i wasn't quite sure what to ask because
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it was my first patient of the day i was
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feeling a little rusty i wasn't in the
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habit of seeing patients i had some time
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off
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and i was like i i'm not quite sure what
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to ask and so i defaulted to using my
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own initial system as a new grad
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i went to old cart ros i asked way too
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many questions but
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more is better than less right so i
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asked basically all 12 body systems
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overview of systems because i was like i
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just want to get all the information i
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can first
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i'll excuse myself and then look some
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more stuff up and the same thing with
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the physical exam i basically did like a
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head to toe assessment because
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for me it's it's fast enough to be able
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to do that at this point where i can
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just jump in and do that whole
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thing but let's go back to this case
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right so just to
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to think about the ros so she had no
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rashes
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joint pain fever chills nausea vomiting
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diarrhea
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no dizziness and no fatigue that is
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specific to the differential but it's
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also like you could just have asked
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those right
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um physical exam so she had a very round
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face and round cheeks
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the it looked i had never seen her
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before and i told her this so i can't
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really assess what her baseline is
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but it was non-pitting it seemed to be
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more like swelling than anything else
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but there was no redness she had a light
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brown skin
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but no underlying erythema and no rashes
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no periorbital edema
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i checked uh had some inclinations to
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start so i looked in to see did she have
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a dorsal fat pad in the back of her
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uh upper back did um and she also had
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diffused silver striae on her abdomen
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um after her pregnancy from four years
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ago but nothing um
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significantly large or like a darkish
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purplish color
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and her face was non-tender there were
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no specific areas of tenderness or pain
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or swelling or redness anything like
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that
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it was kind of like a diffuse both sides
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so she had a normal h-e-e-n-t exam
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aside from that respiratory
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cardiovascular abdominal exam
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those are also all normal and then she
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had no lower extremity edema
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so for differential diagnoses for this
Differential Diagnoses
9:48
case presentation i just wanted to talk
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about my top like the
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grouping of differentials and then like
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my top ones and so again just for
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transparency's sake when i was in that
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visit i was like i'm really not sure
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um there's a couple things i'm thinking
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about but i had to go back and consult
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my resources to make sure i was on the
10:03
right track of what differentials to
10:05
consider and what other history
10:06
questions to ask
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so angioedema is a top one so there's
10:11
actually two different kinds
10:12
mast cell versus bradykine and mediated
10:14
and i'll talk about that in a second
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how you anyway just fun facts there um
10:19
contact dermatitis which is more of a
10:21
dermatological
10:22
topical thing cellulitis eraseopolis
10:25
i've made a video about that as well
10:27
facial lymphedema can be associated with
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rosacea
10:30
that's just lower on the list when it
10:32
comes to diagnoses in terms of
10:34
likelihood
10:36
autoimmune so um i have an angioedema
10:39
and autoimmune in here as both bold
10:40
because those are the ones are
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at the front of my mind and the
10:43
autoimmune conditions
10:45
again transparency as in the remotes
10:47
like is this something like autoimmune
10:49
related
10:50
i'm not quite sure so i didn't have off
10:52
the top of my head the differentials of
10:53
those specific autoimmune conditions
10:55
that can have facial swelling like
10:57
like lupus polymyositis shorgen syndrome
11:00
i never say that right
11:01
and dermatomyositis those are the
11:03
autoimmune conditions that would
11:04
potentially have facial swelling
11:06
but in that moment i just had this
11:07
inclination of like oh is this
11:09
angioedema
11:10
something autoimmune related it's giving
11:12
me that vibe you know
11:14
versus something that's a little bit
11:15
more specific like sle
11:17
things like that anyway a couple of
11:19
other zebra diagnoses to consider
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superior vena cava syndrome and tumors
11:23
can block the blood flow which can cause
11:25
facial swelling
11:26
there's also idiopathic facial swelling
11:28
but that's not necessarily
11:29
um yeah that's not necessarily like
11:33
the first thing that you go to
11:34
hereditary causes and slash other rare
11:37
causes i'm not even getting into that
11:38
because the
11:39
i'll talk about that in a second but the
11:41
way i recommend approaching primary care
11:44
is that is like the must know and then
11:46
the nice to know and when it gets to
11:48
those zebra very rare diagnoses
11:50
typically speaking you're going to get
11:51
those diagnoses from a specialist and
11:53
not from yourself
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as fun as it is to look for zebras it's
11:56
kind of the most important thing is safe
11:58
care and a dealing with the most
12:00
important initial first past things
12:02
first past things
12:04
so salafi salivary gland enlargement is
12:07
important to consider so like is it a
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localized facial swelling on one side
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that's like
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firm or tender the three major glands in
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the face are the parotid gland
12:17
submandibular gland and the sublingual
12:19
gland so if you're palpating someone's
12:21
face do they have any
12:22
like well-demarcated areas that are
12:25
swollen or painful
12:26
um things like that and then cushing's
12:29
syndrome so cushing syndrome was in the
12:31
front of my mind
12:32
because it seemed a little bit like a
12:33
moon face type of um
12:35
morphology so um i have in bold on here
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if you're listening instead of watching
12:39
angioedema
12:40
autoimmune and cushing's syndrome is
12:42
kind of like my first
12:44
leading things because of her physical
12:46
exam because there were no rashes
12:48
no redness no non-tender it was uniform
12:51
on both
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sides um i didn't suspect that celibate
12:54
salivary gland enlargement type of thing
12:57
so i just wanted to touch on those top
12:58
three differentials my thought process
13:00
there if that's helpful
Angioedema
13:02
for you so um just high-level angioedema
13:06
like i could make individual videos
13:07
about each of these diagnoses and it's
13:09
like so hard not to go down that rabbit
13:11
hole because it's so interesting but i
13:12
want to be mindful of your time watching
13:14
this
13:15
video and having it be like a quick win
13:17
for you to remember this stuff
13:19
but um angie edema just quick pearls of
13:22
practice it tends to happen in minutes
13:23
to hours
13:24
it can spontaneously resolve in hours to
13:27
a few
13:27
days there's two different kinds there's
13:30
mast cell the typical angioedema that
13:32
you think of
13:33
which is it causes urecaria flushing
13:36
generalized itching bronchospasm throat
13:38
tightness
13:39
and or hypotension but there's also
13:42
bradykinen
13:43
associated with associated angioedema
13:46
and that's a
13:47
slower developing um angioedema
13:50
facial swelling that develops over 24 to
13:53
36 hours
13:55
and then can go away in about two to
13:56
four days and you don't necessarily have
14:00
you do
14:00
for that type of uh angioedema you do
14:03
not have the other
14:04
things like urticaria and bronchospasm
14:06
throat tightness hypertension etc
14:08
you really just have that facial
14:09
swelling and some of the main causes are
14:12
are some medications like ace inhibitors
14:15
dpp4
14:16
inhibitors there are some fibrinolynic
14:19
agents which are not even worth
14:20
mentioning because it's very rare
14:21
anything that's a rare medication in
14:24
primary care
14:25
i always look at those side effects for
14:27
that patient at that moment to see if
14:28
they're associated i don't necessarily
14:30
memorize
14:31
the fibrinolynic agents that can cause
14:33
angioedema that's not a good use of my
14:34
time in brain space right
14:36
there are resources we can consult to
14:37
look at those things and then hereditary
14:39
causes again those are a little bit of
14:40
zebras so we don't necessarily go
14:42
chasing those right
14:44
just all the other fun pearls about
14:46
angioedema tends to be
14:47
asymmetric not symmetrical it doesn't
14:50
typically doesn't devel
14:51
involve dependent areas so the lower
14:53
extremities don't typically have
14:55
swelling
14:55
it tends to involve the face lips throat
14:59
and bowels
15:00
causing things like nausea vomiting and
15:01
diarrhea and then the person typically
15:04
has some sort of
15:05
history or symptoms of an allergic
15:07
response in the past or allergies or
15:09
a history of anaphylaxis so that's it
Autoimmune
15:12
for angioedema
15:13
it's typically a clinical diagnosis but
15:16
if i had somebody that i suspected
15:17
angioedema i'd probably get the final
15:19
blessing from
15:21
uh an allergy immunology specialist
15:24
so again briefly autoimmune and cushing
15:27
so autoimmune
15:28
the top differentials are lupus and
15:31
polymyositis
15:33
dermatomyositis and shorgen syndrome and
15:36
like i said i could go down a rabbit
15:37
hole for each of these but very high
15:39
level the things that you're thinking
15:41
about with autoimmune that could have
15:42
facial swelling
15:43
are with lupus is is fatigue fever
15:47
weight loss arthralgias rash pleuritis
15:50
most autoimmune conditions have some
15:53
sort of fatigue and joint pain or rashes
15:56
so i always ask that if i have any
15:58
inclination of anything autoimmune
16:00
but the other two are are associated
16:03
with proximal muscle weakness
16:05
and then shorgen syndrome is that ocular
16:07
salivary dryness and that's a little bit
16:08
of a diagnosis of exclusion but
16:10
just general things to keep in mind and
16:12
real talk again going back to the
16:14
patient visit i did not necessarily
16:17
have all these questions in the front of
16:18
my mind or these differentials in the
16:19
front of my mind so
16:21
so i went back and i did my best in that
16:24
visit
16:24
and then i came back and i looked up
16:26
some more stuff and i said oh okay like
16:27
now i'm informing myself more that like
16:29
facial swelling can be from these things
16:32
so to consider working that up like
16:33
angioedema is
16:34
a clinical diagnosis with some
16:36
potentially some other labs to do but
16:38
i would like i said i would probably
16:40
have them see an allergy immunologist
16:42
if i was concerned about that being the
16:44
diagnosis
16:45
and the labs to consider for autoimmune
16:48
you want to think about a tsh
16:50
because hypothyroidism can also cause
16:52
that facial swelling but in the
16:53
in the sense of the other symptoms of
16:55
the autoimmune conditions
16:57
you want to consider a tsh ck
16:59
potentially if they have that proximal
17:01
muscle weakness
17:02
cbc with diff esr crp
17:05
and a cmp so cushing's like real quick
17:09
about cushing so we've learned about
Cushing's
17:11
cushing's in school right but it's nice
17:12
to do a little refresher
17:14
so the main symptoms for cushing are
17:16
decreased libido um
17:18
obesity weight gain round face menstrual
17:21
changes hirsutism
17:22
those abdominal striae are a little bit
17:25
actually less common
17:26
and more common even though they're kind
17:27
of iconic for that diagnosis
17:29
they tend to be on like a darker
17:30
purplish color depending on the
17:32
underlying skin tone of the patient
17:33
and can be one centimeter or larger in
17:36
size
17:37
they can have hypertension easy bruising
17:40
lethargy depression and that dorsal fat
17:42
pad as well as abnormal
17:44
glucose tolerance right so all those
17:46
things that we think about with
17:47
cushing's
17:48
and i thought it was just really fun to
17:50
share that i talked about this case with
17:52
one of my colleagues and we talked about
17:54
um what what to do amazingly what our
17:58
differentials were in like
17:59
our differentials meaning like i came up
18:00
with something and like he told me a lot
18:02
of things because i was not quite sure
18:04
what to do
18:04
and we decided to do an overnight
18:07
dexamethasone
18:08
suppression test for her which i'll talk
18:10
about in just a second
18:12
there's other tests that you can do for
18:13
cushing's like a salivary cortisol test
18:15
and a 24-hour urine cortisol but like
18:18
honestly that is outside the scope of
18:19
primary care so i'm not even going to
18:20
talk about it
18:21
so going back to that case before we
18:23
wrap up just talking about the
18:25
the work up and the next steps for her i
18:28
started with a few tests
18:29
so i did that i ended up doing the
Tests Done
18:32
dexamethasone suppression test
18:34
and it's a screening test and it's not
18:36
diagnostic for cushing's
18:38
and i just wanted to be sure because it
18:40
was it was bilateral both sides like not
18:43
there was no again no redness rash or
18:46
palpable mass and
18:47
non-tender and it wasn't worsening she
18:49
didn't have the other symptoms
18:51
necessarily but i just she just really
18:53
had that strong presentation of that
18:55
like moon phase characteristic
18:57
morphology so um the way that you do
18:59
that is a one milligram
19:01
po dose um around 11 pm at night 8 pm 11
19:04
pm
19:05
and then the next day you check check
19:07
the cortisol level at 8 am
19:10
to see if that cortisol is less than 2
19:12
micrograms per deciliter
19:14
and if it's higher than that then the
19:15
body is not able to kind of suppress the
19:17
dexamethasone basically
19:19
so the labs that i ended up ordering for
19:21
her and in full transparency i did not
19:23
order
19:24
all of these tests the first time around
19:26
and i'm still waiting for those results
19:27
to come back
19:28
but i ordered the cortisol test because
19:30
i ordered the dexamethasone suppression
19:31
test
19:32
i ordered a cbc a cmp
19:35
and i believe an ana and then acth
19:38
and i forgot to do the tsh esr and crp
19:43
so i'm when i when she comes back i will
19:45
have that as my next step
19:47
in the investigation and that's the
19:48
beauty of primary care is that
19:50
we can take things little bits at a time
19:53
and it's okay that i didn't have all of
19:54
those done
19:55
we're we're going to follow up we're
19:57
going to take the next steps we're going
19:58
to see what else is going on there
20:00
and the main reason for ordering the
20:02
cortisol again is for that dexamethasone
20:04
test and then the acth
20:06
is actually um the next step in the
20:09
cortisol
20:09
testing the cushing's workup to see if
20:11
it's you know where the etiology is but
20:14
again you could i could do an entire
20:15
class on all that stuff so it's just
20:17
like very high level brief
20:19
and by the way if you're looking for
20:20
help with lab interpretation like the
20:22
main labs in primary care definitely
20:23
check out the lab interpretation crash
20:25
course
20:26
it'll be really really helpful for you
20:27
if you're struggling with lab
20:28
interpretation and that's at real world
20:30
20:31
labs but aside from that those are the
20:34
labs that i started with
20:36
um cortisol cbc cmp tsh esr
20:40
crp i did an ana which and after looking
20:44
at the literature i probably could have
20:45
skipped that to start
20:47
and um considering a ck and an acth
20:51
as well um so yeah so
20:54
so i'm actually still in the middle of
20:55
this workout for this patient i'm going
20:57
to check on the status of her labs
20:59
and see where we're at in terms of that
21:01
first step that i took with
21:03
some of the labs and then check the ones
21:05
that i did not check yet
21:06
i'm gonna keep i asked her at the time
Summary
21:08
of the visit to keep track of potential
21:10
triggers for her and is it is there
21:11
anything that seems to be making it
21:13
worse
21:13
better or changes at all
21:16
and then the other thing i'm going to
21:18
consider doing again i mentioned this a
21:20
little bit briefly
21:21
is that if it seems like it's more on
21:23
the angioedema side
21:24
if it seems like it's more on the
21:26
endocrine side i would refer those
21:28
patients for a further workup for
21:30
further testing for further diagnostic
21:32
clarity because this
21:33
is an example of something in primary
21:36
care
21:37
that is very uncommon and in fact like i
21:40
talked about this case with my colleague
21:42
who has been a physician for 10 years
21:44
and he said that he's actually only
21:46
ordered one dexamethasone suppression
21:47
test in his
21:48
practice so far so it's very uncommon
21:51
but the reason i wanted to talk about
21:53
this is that
21:54
it's like it's a it's important to
21:56
highlight that there is a system
21:58
that we need to have when we don't know
22:00
what to do
22:01
like off the top of our head that it's
22:03
okay not to memorize things like the
22:05
dexamethasone suppression test and the
22:07
cortisol in the acth lab interpretation
22:09
like
22:10
you have the resources and the knowledge
22:12
base to look at those things when they
22:13
come
22:14
and then the other piece is kind of just
22:17
trying to get a sense of like what
22:19
belongs to primary care
22:20
and what belongs to a specialist and
22:23
what is that space in between
22:25
like what you must know as a primary
22:27
care provider versus
22:29
what like you could do as a primary care
22:31
provider which
22:32
versus what you shouldn't do and give to
22:34
a specialist and that is a piece of
22:36
development of your practice that you
22:38
will fall into over time
22:39
understanding where those lines are but
22:41
i just want to acknowledge that like
22:43
even after six years of being a nurse
22:44
practitioner
22:45
i don't know i don't know i don't have i
22:47
don't know at all and i never will and
22:49
none of us
22:49
ever will it's just important to to
22:52
approach things
22:53
with um a sort of systematic way to
22:56
approach it in place and be watching out
22:57
for the zebras watching
22:59
out for the red flags and having a
23:00
diagnostic approach that you feel really
23:02
comfortable with
23:03
even if you don't have the answers right
23:05
away but hopefully this this was helpful
23:08
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23:09
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23:12
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23:15
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23:21
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23:23
watching
23:24
hang in there and i'll see you soon
23:36
[Music]
23:41
you
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