History:

Date & time: 02/15/23 9:00 am

Full Name: SL

DOB: 01/14/1976

Address: Jamaica, NY

Age: 47 y/o

Sex: Male

Race: African American

Religion: Christian

Source: Pt. himself

Transportation: pt. himself

Reliability: Reliable

Location: Flushing, NY

Chief Complaint: “I feel short of breath” x2 weeks.

History of Present Illness:

47 y/o male PMH of HTN, asthma, and obesity presents to ED c/o SOB for 2 weeks. Pt. states the SOB has gotten progressively worse over time. He states nothing makes his symptoms better, but activity aggravates his symptoms. Pt also reports that the severity of his symptoms is a 7/10. He states that he is coming in today because his wife tested positive for pneumonia last week, so he wants to get checked. Pt. also admits that his sister has a “clotting disorder” and has had a DVT and PE before. Pt reports nonproductive cough and fatigue. Pt denies fever, nausea, vomiting, dizziness, headache, recent travel, chest pain, palpitations, edema, and medication noncompliance.

Past Medical History:

• Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).

Past Surgical History:

• No past surgical history

Medications:

• Metoprolol 50mg BID PO for hypertension.
• Albuterol 2 puffs every 4-6 hours as needed for asthma.
• Denies use of herbal supplements.

Allergies:

• NKDA
• Denies seasonal, food, and animal allergies.

Family History:

• Mother – age 70 alive and well
• Father – age 74 alive and well
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons.

Social History:

• Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use. 
• Travel- Pt. denies any recent travel.
• Marital history- Pt states he has been married to his wife for 6 years.
• Sexual history- pt is a heterosexual male in a monogamous relationship with his wife and denies any h/o STDs.
• Occupational history- pt states he is a mta worker.
• Home situation- Lives with daughter and wife.
• Diet- Pt. states that his diet consists mainly of vegetables, protein, and rice.
• Exercise- Pt. states he does not exercise at all.
• Safety measures– Admits to seat belt use.

Review of Systems:

General – Denies fever, night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite.

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

Head – Denies headaches, vertigo, or head trauma, dizziness.

Eyes – Denies glasses or contact usage, Last eye exam 2021 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus.

Nose/sinuses –Denies discharge obstruction, or epistaxis.

Mouth/throat – Last dental exam February 2022. Denies sore throat, bleeding gums, sore tongue, mouth ulcers, or voice changes.

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

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – See HPI

Gastrointestinal system – Has regular bowel movements daily. Denies abdominal pain, change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

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

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

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

Hematological system –Denies anemia, 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 – Denies depression, anxiety, OCD or ever seeing a mental health professional.

Physical:

General: Obese male, neatly groomed, looks younger than her stated age of 47 years

Vital Signs: BP:                             R                                                       L

                  Seated                        153/99                                               166/94

                  R: 17/min, unlabored                                               P: 114 beats/min, regular

                  T: 97.6 degrees F (oral)                                         O2 Sat: 99% Room air

                  Height: 65-inches              Weight: 240 lbs                  BMI: 39.9

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars.

Hair: average quantity and distribution. 

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.

Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.

Lips –         Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. 

Teeth – Good dentition / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions, or deviation.

Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.

Tonsils grade 1 present with no injection or exudates. Uvula pink, no edema or lesions.

Neck – Trachea midline. No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU. PERRLA, EOMs intact with no nystagmus 
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates, or neovascularization OU.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. non-tender to palpation throughout.

Lungs Basilar crackles appreciated BL. 

Heart: PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Breasts: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions.  No axillary nodes palpable

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non tender to palpation in all four quadrants, with no guarding or rebound noted. Psoas, Obturator, Rovsing, and Murphy’s signs were negative. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Motor/Cerebellar : Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Mental Status: A&O x 3, cooperative, thoughts & speech coherent.

Cranial Nerves: II-XII intact

Sensory: Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes: 2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E  B/L) No stasis changes or ulcerations noted.

Differential diagnosis:

1. CHF- pt. has a risk factor ( HTN and obesity) and is complaining of SOB and cough that worsens with minimal exercise, and is presenting tachycardic. Would order EKG, CXR, echo. Would have ordered CBC, CMP/BMP, troponin, CPK, BNP. Would treat with supplemental O2 and pressors with inotropic meds if hypotensive or Lasix and nitro if hypertensive.
2. Angina- pt. has a risk factor ( HTN and obesity) and is complaining of SOB .SOB occurred after minimal physical exertion and did not resolve immediately with rest. Would have ordered stat EKG. Would order CBC, CMP/BMP, troponin, CPK, CXR, to verify that cardiac markers are not elevated. would treat it with asa, morphine, nitro, and give oxygen.
3. Pulmonary embolism- Pt is c/o SOB that worsens with exertion as well as a cough for the past two weeks and is tachycardic. Pt has a positive family history in his sister who has previously had a DVT and a PE. I would order EKG, CXR, D-DIMER, CBC, CMP, coags, T/S. If D-dimer is positive would follow up with a CT-A to confirm diagnosis. If confirmed for PE would start the patient on heparin or consider fibrinolysis with Ateplase if hemodynamically unstable.
4. Pneumonia- pt is c/o SOB and a cough that has been gradually worsening for the past 2 weeks. He also states that he has had recent exposure because his wife tested positive for pneumonia last week. Would order CBC to check for leukocytosis. BMP to check for hyponatremia, increase in BUN/Cr, or an increase in glucose. Blood gases to observe any alkalosis or acidosis that may be present if pt is in respiratory distress. Cultures to identify the specific pathogen. Lastly a chest x ray to observe any infiltrates.

Assessment: 47 y/o male with PMH of HTN and asthma, past family history of DVT/PE ℅ SOB and cough that has gotten progressively worse over the past 2 weeks.

Plan:

• Get CBC, CMP, T/S, cultures, d-dimer, coags, EKG, CXR, troponin, BNP.
• Start patient on fluid with 2 large bore IVs.
• Place the patient on a cardiac monitor.
• If d dimer returns positive proceed with CT-A.