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History & Physical

Identifying data:

Name: LJ

Sex: Female

Date of birth: 7/13/1963, 58 y/o

Date & Time: 7/14/21, 2:30 pm

Location: Metropolitan Hospital

Marital status: single    

Religion: Catholic

Race: Caucasian   

Source of information: Self, reliable

Mode of transport: Self  

Chief Complaint: shortness of breath x1 day

HPI:

58 y/o F with a PMHx including asthma, DM, GERD, HTN and former smoker (10 cig/d/30 years) presents to the ED complaining of shortness of breath x1 day. Patient reports she was watching a movie last night at 2 am when she got L sided chest pain sudden in onset, sharp, 9/10, radiates from anterior axillary line around the L breast, constant and worse with movement. The pain lasted for 30 minutes, patient couldn’t move for duration of episode, went away spontaneously, she did not take anything for her pain. Patient has never experienced this before. No pain now but patient is complaining of feeling weak, dizzy, chest tightness and difficulty breathing. She tried using her albuterol inhaler but it did not alleviate her symptoms. She states she thinks the breast pain brought on an asthma attack and this is what her past asthma attacks feel like, last one was 1-2 months ago. Patient denies orthopnea, PND, chest pain, nausea/vomiting, fever, recent travel, cough or LE edema. Patient denies recent surgery/cancer/trauma, both sister and mother of pt had blood clots. Pt has hx of one hospitalization for asthma, no intubations, PF on triage: 375.

Past Medical History:

Present illnesses: Asthma, DM, GERD, HTN

Childhood illnesses: none

Immunizations: up to date

Past Surgical History:

Bunionectomy right foot

Hysterectomy

Colonoscopy with biopsy

Partial thyroidectomy

Medications:

Acetaminophen 500 mg tablet

Albuterol 108 mcg/act inhaler

Albuterol 0.083% nebulizer solution

Bisacodyl 5 mg

Budesonide-formoterol (Symbicort) 160-4.5 mcg/act inhaler

Cholecalciferol 50 mcg

Citalopram 20 mg tablet

Diclofenac 1% gel

Diltiazem 180 mg 24 hour capsule

Ergocalciferol 50,000 U

Famotidine 20 mg tablet

Gabapentin powder

Hydroxyzine 25 mg tablet

Meloxicam 15 mg tablet

Prednisone 20 mg tablet

Senno 8.6 mg tablet

Spacer/aero-holding chambers inhaler

Allergies:

Allergic to amoxicillin, metronidazole

Family History:

Mother, sister – DVT

No other significant family history

Social History:

LJ is a 58 y/o female, lives with her daughter.  

Admits to smoking 2 cigarettes/day, used to smoke 10 cigarettes/day/30 years. Denies alcohol or illicit drug use.

Denies sexual activity.

Denies recent travel.

Patient sleeps well, typically 7 hours a night.

Exercise – denies exercise.

Diet – pt tries to maintain a healthy diet.

ROS:

General – Admits to weakness, dizziness. Denies fever, chills, night sweats, fatigue, loss of appetite or recent weight gain or loss. 

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

Head – Denies headache, vertigo, head trauma, unconsciousness, coma or fracture.

Eyes – Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus.

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

Nose/Sinuses – Denies discharge, epistaxis or obstruction. 

Mouth and Throat – Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice 

changes, dentures. Pt’s last dental exam was 6 months ago. 

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

Breast – Denies lumps, nipple discharge or pain.

Pulmonary System – Admits to SOB. Denies dyspnea, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND. 

Cardiovascular System – Admits to chest tightness. Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur. 

Gastrointestinal System – Denies change in appetite, intolerance to foods, dysphagia, pyrosis, flatulence, eructation, nausea, vomiting, diarrhea, abdominal pain, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, stool guaiac/colonoscopy/sigmoidoscopy or pain in flank.

Genitourinary – Denies urinary frequency, change in color of urine, incontinence, dysuria, hematuria, nocturia, urgency, oliguria or polyuria.

Sexual History – Denies sexual activity.. Denies anorgasmia, known sexually transmitted infections or the use of contraception/protection. 

Menstrual and Obstetrical – Denies dysmenorrhea, menorrhagia, metrorrhagia, vaginal discharge, PMS, postcoital bleeding, dyspareunia or menopause. LMP – 01/01/2001

Obstetrical History – G2T0111

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

Peripheral Vascular System – Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change. 

Hematologic System – Denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE. 

Endocrine System – Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism. 

Nervous System – Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness.

Psychiatric – Denies depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional. 

Physical Exam:

General: 

58 y/o female A&O x3. Patient appears her stated age, is well-appearing, not in acute distress. Patient is able to speak in full sentences.

Vital Signs: 

BP: 127/70 (L arm, sitting)

R: 16 breaths/min unlabored 

P: 73 beats/min, regular rhythm 

T: 98.0 degrees F (oral) 

O2 Sat: 100% Room Air

BMI: 28.94

Skin, Hair, Nails and Head:

Skin: Warm & moist, good turgor, smooth texture, non-icteric. No thickness, opacities noted. No lesions, masses, scars or tattoos noted. 

Hair: Average distribution and quantity. 

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

Head: Normocephalic, atraumatic, no deformities and specific faces noted, non-tender to palpation throughout.

Eyes:

Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No strabismus, exophthalmos or ptosis. Sclera white, conjunctiva clear. 

Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

Ears:

Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose: 

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated.

Sinuses:

Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth:

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. 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 noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, 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 palpable adenopathy noted.

Thyroid: 

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

Thorax & Lungs: 

Chest – symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles notes. Lat to AP diameter 2:1. Non-tender to palpation. 

Lungs – clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds (wheezing). 

Heart:

Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

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 throughout. Tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. Murphy’s sign, Rovsing’s sign and McBurney’s point are all negative.

Mental Status:

Patient is awake, alert, oriented and attentive. No slurred speech, aphasia. Complete comprehension and insight, memory intact, reliable historian.

Peripheral Nervous System:

Steady gait, no ataxia. No tics, tremors or fasciculations noted. Full PROM and AROM of all extremities. 5/5 strength throughout, 2+ DTRs.

Peripheral Vascular: 

Skin is normal in color, warm to touch, no calf tenderness bilaterally, equal in circumference. No palpable cords or varicose veins bilaterally. No cyanosis, clubbing or edema bilaterally.

Musculoskeletal:

No tenderness or pain in any joints or muscles. No soft tissue swelling, ecchymosis, atrophy, crepitus in bilateral UE and LE. Can bend both knees and lift legs to 45 degrees without difficulty. Can raise both arms to horizontal or above. No evidence of spinal deformities.

Differential diagnoses:

  • Asthma attack
  • DVT/PE
  • ACS/MI
  • GERD

Labs: 

CBC:

WBC – 6.83

RBC – 4.19

HGB – 12.9

HCT – 39.3

MCV – 93.8

MCH – 30.8

MCHC – 32.8

PLT – 279

Abs neutrophil – 3.27

BMP:

Na – 140

PO4 – 4.5

Cl – 103

CO2 – 29

BUN – 13

Cr – 0.7

Ca – 10

Glucose – 99

Anion gap – 8.0

eGFR – 95.8

LFTS:

ALT – 10

AST – 14

Alkphos – 65

Albumin – 4.6

D-dimer – 65

Troponins – <0.010

Imaging:

CXR – chest PA and lateral views

  • Calcified granuloma seen in R upper lobe overlying R clavicle. Unchanged since previous studied (compared to CXR on 4/30/2021 and chest CT 3/18/2017). No focal infiltrate is seen in lungs. No evidence of pleural effusion or pneumothorax.

ECG –

  • Sinus rhythm, 63 bpm
  • Normal ECG

Assessment/Plan:

58 y/o female presents to the ED with shortness of breath x1 day

R/O PE, ACS

Medlock/IV line, duo nebs, aspirin 

BMP to evaluate for electrolyte abnormalities and anion gap acidosis

CBC to evaluate for anemia and thrombocytopenia

Hepatic function panel to evaluate for transaminitis and biliary disease

Troponin to evaluate for cardiac ischemia

D-dimer to evaluate for DVT vs PE

EKG to evaluate for arrhythmias or cardiac ischemia

CXR to evaluate for cardiopulmonary pathology/infection/masses

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