Transcript: Facial Swelling Case Study for Nurse Practitioners

​Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly videos to help save you time, frustration and help you learn faster so you can take the best care of your patients. In this week's episode, I want to talk about a case study of a patient that I saw the other day. And the reason I'm talking about it, it's not the most common diagnosis or chief complaint to see in primary care, but what I really loved about it is how it really brought me back to my new nurse practitioner roots of basically the situation of, I don't actually know what to do here. And when I was a new grad, I felt like that all the time. So on the one hand, it's an interesting case with an interesting workup that's still underway, but I will report back in the comments below when I have the results and the outcome of what happened, but also highlights how to approach a situation where you're not quite sure what to do with the chief complaint that is sitting in front of you in the room.

So without further ado, I'm going to share my screen with you and I'm going to talk about a patient with facial swelling. So I hope you enjoy. Okay, so this is the case study about the woman with facial swelling. So this is Maria. This is, if you're watching versus listening, this is not her real name or her photo. She was a 34-year-old female that came in to see me the other day and her chief complaint was for facial swelling. So she noticed facial swelling about a month ago. When I asked her about her symptoms, she said sometimes it's better in the morning and then gets worse throughout the day, but it's really different each day. Sometimes it's the same all the time, sometimes it's better in the morning. She doesn't have any itching, pain, redness, and the symptoms aren't worsening at all. They've just been the same for the last month.

Her mother also noticed that her cheeks were more swollen looking than they were before. She hasn't done any treatment for it in terms of ointments or medications or anything like that. And as far as she knows, there was nothing that started the symptoms a month ago. She just happened to more or less gradually notice it happening. She's never had it happen before. And if you listen to any other, or listen to or watch any of the other episodes, you'll know that this is a really key question that I always recommend asking when it comes to the history, because a lot of patients will forget to volunteer that information that they've actually had this before, they've had this whole treatment because a lot of patients assume that we have records for basically everything that's ever happened to them. And that is not always the case unfortunately.

And then she was wondering if it was, she's done her own research, but she's also been wondering if it's body weight related. And so she has been going to the gym regularly. She drinks adequate amounts of water and stays hydrated. She's eating a healthy diet, she's been trying to lose weight and it doesn't seem to impact her facial swelling at all. So for past medical history, she has a BMI of 33. She has one child, one pregnancy, and one life child who's four years old. Otherwise, she has no other medical issues that she knows about. She doesn't have any past surgical history or family history aside from a BMI that's greater than 30 in her family members. But she denies any history of these symptoms or cancers or any of the major causes of death of her family, ASCVD, cancer, diabetes, hypertension, things like that. So none of that, that she knows of.

She does not take any medications or supplements. And her blood pressure at the time of the visit was 122 over 78, heart rate of 72. Oxygen was normal at 98%. And then her BMI again was 33. Her last menstrual period was 25 days ago. And she says that it's regular and it happens every 27 days on the dot. She has one cis male partner and uses condoms for contraceptives because she's not interested in getting pregnant at this time. And so that's the background information. And in presenting this case, my goal with presenting this case is presenting the real world situation because I think it's so, I don't know, it's such a hard transition to practice that you learn about all of these things in school and then you see real patients in front of you. And one of the conundrums is that patients will come with a chief complaint of something and then when you get into the room it's potentially something else.

So in this case, her chief complaint of facial swelling was actually facial swelling. But before I get into the actual physical exam part, I just wanted to pause, if you want to pause here, you can think about other history questions that you want to ask. But I just want to say that this case I love because it really reminded me of when I was a new nurse practitioner and I felt like I didn't know anything when in fact I did. But there's a lot of learning that you do as you go, but this scenario of having a chief complaint that either you're not prepared for because it's different from what the patient has said before you got into the room, to the medical assistant, or to the call center, or to the administrative staff who booked the appointment versus what you get when you're in the room, that's always an opportunity or possibility because as much as we try to prepare ahead of time, we can't always.

And so this is an example of a situation for me as an experienced nurse practitioner, I was like, I'm not quite sure what to do. And so I just relied on those past ways that I've dealt with cases as a newer nurse practitioner and defaulting to that pattern of if I don't know what to do, what is the system I have to use to support myself? So first thing's first is OLDCART. And I've talked about this before in other episodes, but I recommend having some systematic process of asking or history questions. And the way I've presented it, I've actually covered all of those OLDCART systems. So OLDCART is that acronym for history taking where it's onset, location, duration, characteristics, associated factors, relieving factors and time. So you're asking about when it started, where it is, if it comes and goes, what the characteristics are, what the treatments are, things like that.

So if you don't know what you're doing, if you don't feel like you know what you're doing or you're unprepared in that moment to handle facial swelling, differential diagnosis, always default to what your system is. And I use OLDCART and I recommend doing that. The other hack, which I've talked about before as well, is asking the review of systems questions. And honestly, if you're not sure, the hack is to just pick a system, ask the whole thing, and then you get to excuse yourself, look some stuff up and then ask more questions if you've forgotten them. But that's the, again that safety default of what can I do to get the most history, most helpful situation for this patient in this moment. And then I also love the question, is it getting worse, better or staying the same? Again, in that history presentation I just did, I talked about all those things already, but those are things to consider if you haven't already in your history taking.

And again, have you had this happen before? And then your history questions, the further history questions you can ask will be based on your differential diagnosis. And like I said, if you're not sure what to do with a patient for that chief complaint, you might not know what those differentials are off the top of your head, and that is okay. You have resources to consult, go back and look at them and ask those questions. But the hack way around that is to ask the OLDCART framework of questioning for history as well as choosing the ROS that is specific to that chief complaint, and then the other potentially associated reviews of systems, the body systems that are potentially related.

And that's just to be really transparent, I'm trying to be a lot more candid, as candid as I can be on this channel about what the real world is like. I wasn't quite sure what to ask because it was my first patient of the day, I was feeling a little rusty. I wasn't in the habit of seeing patients. I'd had some time off and I was like I'm not quite sure what to ask. And so I defaulted to using my own initial system as a new grad. I went to OLDCART, ROS, I asked way too many questions, but more is better than less. So I asked basically all 12 body systems a review of systems because I was like, I just want to get all the information I can first. I'll excuse myself and then look some more stuff up. And the same thing with the physical exam. I basically did a head to toe assessment because for me it's fast enough to be able to do that at this point where I can just jump in and do that whole thing.

But let's go back to this case. So just to think about the ROS. So she had no rashes, joint pain, fever, chills, nausea, vomiting, diarrhea, no dizziness and no fatigue. That is specific to the differential, but it's also, you could just have asked those. Physical exam. So she had a very round face and round cheeks. It looked... I had never seen her before and I told her this, so I can't really assess what her baseline is, but it was non-pitting, it seemed to be more swelling than anything else. But there was no redness. She had light brown skin but no underlying erythema and no rashes, no periorbital edema. I checked, had some inclinations to start. So I looked in to see did she have a dorsal fat pad in the back of her upper back? And she also had diffuse silver striae on her abdomen after her pregnancy from four years ago, but nothing significantly large or a darkish purplish color. And her face was non-tender. There were no specific areas of tenderness or pain or swelling or redness, anything like that. It was like a diffuse both sides.

So she had a normal HEENT exam aside from that. Respiratory, cardiovascular abdominal exam, those were also all normal. And then she had no lower extremity edema. So for differential diagnoses, for this case presentation, I just wanted to talk about my top, the grouping of differentials and then my top ones. And so again, just for transparency's sake, when I was in that visit, I was like, I'm really not sure. There's a couple things I'm thinking about, but I had to go back and consult my resources to make sure I was on the right track of what differentials to consider and what other history questions to ask.

So angioedema is a top one. So there's actually two different kinds, mast-cell versus bradykinin-mediated, and I'll talk about that in a second, how you would... Anyway, just fun facts there. Contact dermatitis, which is more of a dermatological topical thing. Cellulitis, erysipelas, I've made a video about that as well. Facial lymphedema can be associated with rosacea. That's just lower on the list when it comes to diagnoses in terms of likelihood. Autoimmune, so I have an angioedema and autoimmune in here as both bold because those are the ones are at the front of my mind. And the autoimmune conditions, again, transparency. I was in the room, I was like, is this something autoimmune related? I'm not quite sure. So I didn't have off the top of my head the differentials of those specific autoimmune conditions that can have facial swelling like lupus, polymyositis, Sjogren's syndrome, I never say that right. And dermatomyositis, those are the autoimmune conditions that would potentially have facial swelling.

But in that moment, I just had this inclination of, oh, is this angioedema, something autoimmune related? It's giving me that vibe versus something that's a little bit more specific like SLE, things like that. Anyway, a couple of other zero diagnoses to consider. Superior vena cava syndrome and tumors can block the blood flow, which can cause facial swelling. There's also idiopathic facial swelling, but that's not necessarily, yeah, that's not necessarily the first thing that you go to. Hereditary causes and/ other rare causes, I'm not even getting into that because the... I'll talk about that in a second. But the way I recommend approaching primary care is the must know and then the nice to know. And when it gets to those zebra, very rare diagnoses, typically speaking, you're going to get those diagnoses from a specialist and not from yourself.

As fun as it is to look for zebras, the most important thing is safe care and a dealing with the most important initial first past things. So salivary gland enlargement is important to consider. So is it a localized facial swelling on one side that's like firm or tender? The three major glands in the face are the parotid gland, submandibular gland, and the sublingual gland. So if you're palpating someone's face, do they have any well demarcated areas that are swollen or painful, things like that. And then Cushing's syndrome. So Cushing's syndrome was in the front of my mind because it seemed a little bit like a moon face type of morphology. So I have in bold on here if you're listening, instead of watching, angioedema, autoimmune and Cushing's syndrome as my first leading things because of her physical exam, because there were no rashes, no redness, non-tender, it was uniform on both sides. I didn't suspect that salivary gland enlargement type of thing.

So I just wanted to touch on those top three differentials, my thought process there, if that's helpful for you. So just high level angioedema, I could make individual videos about each of these diagnoses. And it's so hard not to go down that rabbit hole because it's so interesting, but I want to be mindful of your time watching this video and having it be a quick win for you to remember this stuff. But angioedema, just quick pearls of practice, it tends to happen in minutes to hours. It can spontaneously resolve in hours to a few days. There's two different kinds. There's mast-cell, the typical angioedema that you think of, which is it causes urticaria, flushing, generalized itching, bronchospasm, throat tightness and, or hypotension. But there's also bradykinin associated angioedema. And that's a slower developing angioedema facial swelling that develops over 24 to 36 hours and then can go away in about two to four days.

And you don't necessarily have, for that type of angioedema, you do not have the other things like urticaria and bronchospasm, throat tightness, hypertension, et cetera. You really just have that facial swelling. And some of the main causes are some medications like ACE inhibitors, DPP4 inhibitors. There are some fibrinolytic agents which are not even worth mentioning cause it's very rare. Anything that's a rare medication in primary care, I always look at those side effects for that patient at that moment to see if they're associated. I don't necessarily memorize the fibrinolytic agents that can cause angioedema. That's not a good use of my time and brain space. There are resources we can consult to look at those things.
And then hereditary causes, again, those are a little bit of zebra, so we don't necessarily go chasing those. Just all the other fun pearls about angioedema tends to be asymmetric, not symmetrical. And it typically doesn't involve dependent areas. So the lower extremities don't typically have swelling. It tends to involve the face, lips, throat, and bowels causing things like nausea, vomiting, and diarrhea. And then the person typically has some sort of history or symptoms of an allergic response in the past or allergies or a history of anaphylaxis. So that's it for angioedema, it's typically a clinical diagnosis, but if I had somebody that I suspected angioedema, I'd probably get the final blessing from an allergy immunology specialist. So again, briefly, autoimmune and Cushing. So autoimmune, the top differentials are lupus and polymyositis/ dermatomyositis and Sjogren's syndrome. And like I said, I could go down a rabbit hole for each of these, but very high level, the things that you're thinking about with autoimmune that could have facial swelling are, with lupus is fatigue, fever, weight loss, arthralgias, rash, pleuritis.

Most autoimmune conditions have some sort of fatigue and joint pain or rashes. So I always ask that if I have any inclination of anything autoimmune. But the other two are associated with proximal muscle weakness. And then Sjogren's syndrome is that ocular salivary dryness. And that's a little bit of a diagnosis of exclusion, but just general things to keep in mind and real talk. Again, going back to the patient visit, I did not necessarily have all these questions in the front of my mind or these differentials in the front of my mind. So I went back and I did my best in that visit. And then I came back and I looked up some more stuff and I said, oh, okay, now I'm informing myself more that facial swelling can be from these things. So to consider working that up, like angioedema is a clinical diagnosis with potentially some other labs to do. But like I said, I would probably have them see an allergy immunologist if I was concerned about that being the diagnosis.

And the labs to consider for autoimmune. You want to think about a TSH because hypothyroidism can also cause that facial swelling, but in the sense of the other symptoms of the autoimmune conditions, you want to consider a TSH, CK potentially if they have that proximal muscle weakness. CBC with diff, ESR/ CRP and a CMP. So Cushing's, real quick about Cushing's. So we've learned about Cushing's in school, but it's nice to do a little refresher. So the main symptoms for Cushing are decreased libido, obesity, weight gain, round face, menstrual changes, hirsutism, those abdominal striae are a little bit actually less common than more common, even though they're iconic for that diagnosis. They tend to be on a darker purplish color, depending on the underlying skin tone of the patient and can be one centimeter or larger in size. They can have hypertension, easy bruising, lethargy, depression, and that dorsal fat pad as well as abnormal glucose tolerance. So all those things that we think about with Cushing's.

And I thought it was just really fun to share that I talked about this case with one of my colleagues and we talked about what to do and basically what our differentials were and our differentials, meaning I came up with something and he told me a lot of things because I was not quite sure what to do. And we decided to do an overnight dexamethasone suppression test for her, which I'll talk about in just a second. There's other tests that you can do for Cushing's, like a salivary cortisol test and a 24-hour urine cortisol. But honestly, that is outside the scope of primary care, so I'm not even going to talk about it. So going back to that case, before we wrap up, just talking about the workup and the next steps for her, I started with a few tests.

So I ended up doing the dexamethasone suppression test, and it's a screening test and it's not diagnostic for Cushing's. And I just wanted to be sure because it was bilateral, both sides, there was no, again, no redness, rash, or palpable mass and non-tender, and it wasn't worsening. She didn't have the other symptoms necessarily, but she just really had that strong presentation of that moon face characteristic morphology. So the way that you do that is a one milligram PO dose around 11:00 PM at night, 8:00 PM, 11:00 PM. And then the next day you check the cortisol level at 8:00 AM to see if that cortisol is less than two micrograms per deciliter. And if it's higher than that, then the body is not able to suppress the dexamethasone basically. So the labs that I ended up ordering for her, and in full transparency, I did not order all of these tests the first time around, and I'm still waiting for those results to come back.

But I ordered the cortisol test because I ordered the dexamethasone suppression test. I ordered a CBC, a CMP, and I believe an ANA and an ACTH, and I forgot to do the TSH, ESR, and CRP. So when she comes back, I will have that as my next step in the investigation. And that's the beauty of primary care is that we can take things little bits at a time and it's okay that I didn't have all of those done. We're going to follow up, we're going to take the next steps, we're going to see what else is going on there. And the main reason for ordering the cortisol, again, is for that dexamethasone test. And then the ACTH is actually the next step in the cortisol testing the Cushing's workup to see if it's where the etiology is. But again, I could do an entire class on all that stuff. So it's just very high level brief.

And by the way, if you're looking for help with lab interpretation, like the main labs in primary care, definitely check out the Lab Interpretation Crash course. It'll be really, really helpful for you if you're struggling with lab interpretation. And that's at realworldnp.com/labs. But aside from that, those are the labs that I started with. Cortisol, CBC, CMP, TSH, ESR, CRP. I did an ANA, which after looking at the literature, I probably could have skipped that to start and considering a CK and an ACTH as well. So yeah, I'm actually still in the middle of this workup for this patient. I'm going to check on the status of her labs and see where we're at in terms of that first step that I took with some of the labs. And then check the ones that I did not check yet.

I asked her at the time of the visit to keep track of potential triggers for her, and is there anything that seems to be making it worse, better, or changes at all? And then the other thing I'm going to consider doing, again, I'd mentioned this a little bit briefly, is that if it seems like it's more on the angioedema side, if it seems like it's more in the endocrine side, I would refer those patients for a further workup, for further testing, for further diagnostic clarity, because this is an example of something in primary care that is very uncommon. And in fact, I talked about this case with my colleague who's been a physician for 10 years, and he said that he's actually only ordered one dexamethasone suppression test in his practice so far.

So it's very uncommon. But the reason I wanted to talk about this is that it's like, it's important to highlight that there is a system that we need to have when we don't know what to do off the top of our head, that it's okay not to memorize things like the Dexamethasone suppression test and the cortisol and the ACTH lab interpretation. You have the resources and the knowledge base to look at those things when they come. And then the other piece is just trying to get a sense of what belongs to primary care and what belongs to a specialist, and what is that space in between, what you must know as a primary care provider versus what you could do as a primary care provider, which versus what you shouldn't do and give to a specialist. And that is a piece of development of your practice that you will fall into over time, understanding where those lines are.

But just want to acknowledge that even after six years of being a nurse practitioner, I don't know it all, and I never will, and none of us ever will. It's just important to approach things with a systematic way to approach it in place and be watching out for the zebras, watching out for the red flags, and having a diagnostic approach that you feel really comfortable with, even if you don't have the answers right away. But hopefully this was helpful for you. If you haven't grabbed the ultimate resource guide for the new NP, head over to realworldnp.com/guide. You'll also get all these videos sent straight to your inbox every week with notes from me, patient stories and bonuses I really just don't share anywhere else. Thank you so much for watching. Hang in there and I'll see you soon.