Identifying Data

Name: Female

Address: NYQH

Date of Birth: 67 y/o

Location: NYHQ

Source of Information: Self

 

Chief Complaint: shortness of breath x1 week

History of Present Illness:

67 y/o female with PMH of COPD, asthma, CAD s/p MI x2 stents 2012, CHF, HTN, HLD, type 2 DM, Parkinson’s disease, renal cell carcinoma s/p right nephrectomy 1998, anxiety, depression presenting with worsening shortness of breath for 1 week. Associated with subjected fever, chills, productive cough of yellow phlegm, and chest pain only with cough. Patient was seen by PMD 1 week ago and diagnosed with pneumonia, for which she was started on Penicillin and completed course with worsening symptoms, prompting ED visit. Patient states dyspnea is worsened when lying down and on exertion and also admits to wheezing and bilaterally lower extremity edema. Patient has been increasingly fatigued over the last 3 weeks. Denies hemoptysis, cyanosis, palpitations, or syncope. Denies any recent travel, nausea, vomiting, or abdominal pain.    

 

Past Medical History:

Asthma

COPD

CAD/ MI

Renal Cell carcinoma 

Type 2 DM

HTN

HLD

 

Past Surgical History:

Angioplasty 2012

Nephrectomy 

Tubal ligation (both)

 

Medications:

Prednisone 20 mg PO 2 tab once daily

Symbicort 160 mcg 4.5 mcg/inh inhalation aerosol 2 puffs 2x daily 

Montelukast 10 mg PO tab once daily 

Clopidogrel 75 mg PO tab once daily 

Gabapentin 100 mg PO tab 3 times daily 

Citalopram 10 mg PO tab once daily 

Carbidopa-levodopa 25 min-100 mg PO tab once daily 

Atorvastatin 80 mg PO tab once daily

Aripiprazole 5 mg PO tab once daily

Carvedilol 12.5 mg PO tab once daily 

Lasix 20 mg PO tab once twice daily 

Lantus solostar Pen 100 units/ mL subcutaneous solution 60 units daily 

Novolog 100 units/ mL subcutaneous solution 20 units daily 

 

Allergies:

Erythromycin – hives

Azithromycin – hives 

 

Family History:

Father – type 2 diabetes 

Mother – HTN, HLD 

 

Social History:

Patient lives home with husband. Denies drinking alcohol, smoking or using illicit drugs. Denies a history of sexually transmitted diseases. 

 

Review of Systems:

General – Admits to fever, chills, fatigues. Denies recent weight loss or gain, night sweats.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headache, vertigo or head trauma.

Eyes – Denies pruritus, lacrimation, corrective lenses, photophobia or other visual disturbances.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. 

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

Breast – Denies any changes in breast, discharge, lumps.

Pulmonary system – see HPI

Cardiovascular system – see HPI

Gastrointestinal system – Denies change in weight, intolerance to food, dysphagia, pyrosis, jaundice, constipation, or blood in stool

Genitourinary system – denies urinary frequency or urgency, oliguria, polyuria or dysuria. 

Menstrual/ Obstetrical – G2P2. Menarche age 11. Menopause age 51. Denies bleeding/ spotting or vaginal discharge.

Nervous – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematological system – Denies anemia, easy bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – History depression or anxiety. Denies OCD or other psychiatric disorders. 

 

Physical Exam

Vitals 

Pulse:96, regular 

BP: 219/104

RR: 29, labored 

Temperature: 99.4 F oral

Pulse ox: 85% on room air 

Weight: 97.3 kg

 

General – AOX3, awake, in respiratory distress

HEENT – no masses, lesions, deformities. PERRL, EOM. No nasal discharge, exudates, lymphadenopathy, erythema. Trachea midline

Skin – warm and dry, good turgor. No rashes, bruises, or masses.  

Cardiac – regular rate and rhythm. No murmurs/rubs/gallops. No JVD or carotid bruits. 

Lungs – diffuse wheezing in bilateral lung fields. Tachepnic, hypoxic to 85% on room air 

Abdominal – Bowel sounds present in all quadrants. Abdomen soft. Non tender and non distended. No CVA tenderness. No aortic/ renal bruits. No organomegaly.

Musculoskeletal – Pain on palpation of ribs. No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. FROM in upper and lower extremities b/l. No spinal deformities. 

Peripheral Vascular – Color and temperature wnl. Pulses 2+ bilaterally in upper and lower extremities b/l. No cyanosis, clubbing or edema. No palpable varicose veins.

Neurological – AOx3. Memory and attention intact. Receptive and expressive abilities intact. No dysarthria, dystonia or aphasia. 

CN: grossly intact. Strength grossly intact. Sensory grossly intact. 

 

Labs/Diagnostics

CMP

135| 99 | 22.7  < 210

6.0 | 26 | 1.45

 

CBC

7.87>9.0< 222

          30.5

 

PT 12.0

PTT 28.1

INR 1.05

Troponin 0.042

 

Albumin 3.7

Bilirubin 0.2

AST 25

Alk phosphatase 102

 

Procalcitonin 0.12 ng/mL

NT-ProBNP 1251 pg/mL

 

CXR – b/l pulmonary edema 

 

Assessment and Plan

67 y/o female with PMH of COPD, asthma, CAD s/p MI x2 stents 2012, CHF, HTN, HLD, type 2 DM, Parkinson’s disease, renal cell carcinoma s/p right nephrectomy 1998, anxiety, depression presenting with worsening shortness of breath for 1 week. 

 

DDX: COPD/ CHF exacerbation 

1. Pneumonia  
2. Bronchitis 
3. Pulmonary embolism
4. Influenza/ viral respiratory infection 

 

Plan:

1. Patient refusing bipap, give oxygen via NC at 5 liters
2. Labs, CXR ordered to evaluate for pneumonia 
3. Order ecg
4. Start on Duodeb and methylprednisone 125mg IV
5. Order respiratory viral panel