Site Evaluator: Professor Rachwalski
I presented the following case at my first site evaluation:
LJ is a 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.
Patient’s PMHx is significant for asthma, DM, GERD, HTN and former smoker (10 cigarettes/day/30 years). Surgical history includes bunionectomy R foot, hysterectomy, colonoscopy with biopsy and partial thyroidectomy. Family history includes DVT in mother and sister.
Pt is taking 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, Diltiazem180 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 and spacer/aero-holding chambers inhaler.
Patient’s vitals: BP – 127/70 (L arm, sitting), RR: 16 breaths/min unlabored, Pulse: 73 beats/min regular rhythm, Temp: 98.0 degrees F, O2 sat – 100% on room air, BMI – 28.94. PE is unremarkable – no change in LE skin color, warmth, edema or calf tenderness B/L.
Patient’s labs were within normal limits – d-dimer was 65, troponins <0.010. CXR was unchanged from previous one, no evidence of acute abnormalities. EKG showed sinus rhythm, 63 bpm, no abnormalities seen.
Patient was likely having an asthma exacerbation. She was given albuterol inhaler and prednisone in the ED and discharged.
Professor Rachwalski gave great feedback and helped & critiqued me in the areas which needed strengthening. He reminded me of the most important things we want to rule out in the ED with a case like this one. He offered information which aided in my knowledge of emergency medicine!
