I presented this H&P at my second site visit with PA-C Andrea Pizzaro:
DK is a 71 y/o F with a 50 pack year history and PMHx of osteopenia, eczema and HLD presents to the ED complaining of chest pain and shortness of breath for 2 days. Patient states the day before the onset of these symptoms, she noticed bilateral lower extremity swelling. Patient states her chest pain onset was at rest when she was sitting on her couch, is left-sided, intermittent, sharp, non-radiating, 3/10 in severity. Chest pain is described as “discomfort”, is non-exertional with no alleviating or exacerbating factors. Patient’s shortness of breath worsens when she is exerting herself and gets better with rest. Patient states she has never experienced this chest pain or shortness of breath before, however she has experienced the bilateral LE swelling 1 year ago. States she thought it was due to her eczema so she took Clobetasol and it reportedly went away overnight. Otherwise, patient has had no similar episodes. Patient admits to non-productive cough and anxiety which she states could be the cause of her chest pain after seeing her swollen legs. Patient denies N/V/D, fever, chills, recent travel, hx of frequent URIs, new onset fatigue, lack of energy or decrease in exercise tolerance.
In the ED, patient was found to be hypoxic to 88% on RA and placed on 2L NC. Troponins are negative, BNP 300. CXR showed hyperinflated lungs. Admitted for further management of acute hypoxic respiratory failure 2/2 New COPD vs New onset CHF exacerbation.
ED initial vital signs: BP: 155/83, R arm sitting, Pulse: 102 beats/min, regular rhythm, RR: 20 breaths/min, unlabored, Temp: 36.6 C/97.8 F, SpO2: 88% on room air.
Patient given Duoneb (Ipratropium Bromide and Albuterol Sulfate) and ASA 324 mg tablet in the ED.
Past Medical History: Osteopenia (diagnosed 2017), HLD (diagnosed 2010), Eczema (diagnosed 1965).
Past Surgical History: L breast biopsy (01/2021).
Family History: Mother – MI at age 78, Father – MI at age 76. Patient doesn’t have any children, no other significant family history.
Allergies: Dust, pollen, many foods, Benadryl and sulfa.
Medications: multivitamin.
Social History: DK is a single female with no children, lives alone in her apartment, works in a school. Admits to smoking tobacco 1 pack per day for the past 50 years/50 pack year history. Denies alcohol use, smokeless tobacco or other illicit drug use. Is not sexually active, denies history of sexually transmitted diseases. Appetite is normal, patient usually sleeps well 6 hours a night. Patient does yoga. Denies recent travel, or recent surgery.
ROS: positive for non-productive cough, SOB, chest pain, edema/swelling of bilateral LE.
Physical Exam: 71 y/o female is alert and oriented to person, place and time. Is interactive, looks her stated age of 71, well appearing and is not in acute distress.
Vital Signs: BP: 135/75, R arm supine, R: 20 breaths/min, unlabored, P: 95 beats/min, regular rhythm, T: 36.7 C/ 98.6 F (oral), O2 Sat: 93% on NC, Height: 5’1”, Weight: 46.3 kg/102 lb, BMI: 19.3 kg/m2.
Nails: cannot assess for clubbing or capillary refill – patient wearing acrylic nails and refuses to remove them.
Cardiology: tachycardia, regular rhythm, S1 and S2 with no murmurs.
Pulmonary: respirations unlabored, no use of accessory muscles. Expiratory wheezing bilaterally.
Abdomen: flat, soft, bowel sounds normoactive, no tenderness to palpation.
Musculoskeletal: 2+ pitting edema noted on bilateral LE up to the shins, no erythema or tenderness to palpation.
Labs: WBC 6.37, RBC 5.27, HgB 15.4, HCT 49.2, CO2 32, BUN 23.7, BUN/Cr 41, BNP 328, D-dimer 175. ABG: pH 7.326, CO2 61.6, O2 57.6.
Imaging: CXR – hyperinflated lungs which may represent obstructive pulmonary disease. US venous b/l LE – no evidence of DVT. ECG 12 lead – sinus tachycardia at 102, normal rhythm, normal interval lengths, no ischemic changes.
Assessment: DK is a 71 y/o F with a 50 pack year history presents to the ED complaining of chest pain and shortness of breath for 3 days associated with bilateral leg swelling. In the ED, patient was hypoxic on RA, now on 2L NC. Troponins negative, BNP 300, CXR showed hyperinflated lungs. Admit for further management of acute hypoxic respiratory failure.
Plan: #Acute hypoxic respiratory failure 2/2 new COPD
- Hypoxic on RA 88% in the ED, now on 2L NC
- R/o ACS – troponin negative x2, follow up 3rd set, negative ECG
- R/o CHF – BNP negative
- CXR showed hyperinflated lungs 2/2 obstructive pulmonary disease
- EKG showed no acute ST elevation, T wave inversion
- s/p duonebs and ASA in ED. Continue with duonebs q6h
- will give solumedrol (methylprednisolone) 125 mg x1 and continue with solumedrol 40 mg q8h
- O2 supplementation as needed, taper as tolerated
- Monitor on tele
#GI/DVT prophylaxis
- Protonix (Pantoprazole) 40 mg qd / Lovenox (Enoxaparin) 30 mg SQ qd
Patient Education: I would explain to the patient that she likely has chronic obstructive pulmonary disease, a group of diseases that causes airflow blockage and breathing-related problems. COPD includes emphysema, where the alveoli are destroyed, and chronic bronchitis, where there is inflammation of the lining of the bronchial tubes. Symptoms of COPD include difficulty breathing, shortness of breath, cough and wheezing. It’s most commonly caused by long-term exposure to cigarette smoke. Although there is no cure for COPD, there are ways to treat it and prevent exacerbations which is important for morbidity as COPD is a progressive disease which worsens overtime and for preventing other diseases including heart disease and lung cancer. The first most important intervention is smoking cessation. Quitting to smoke s the best way to prevent further damage to your lungs. I would also explain that avoiding exposure to pollutants including dust, fumes and cigarette smoke is also important. It is imperative that the patient follows closely with her PCP and is compliant with her new medications which may include bronchodilators to help relax the muscles in her airways, steroids which decrease airway inflammation or combination inhalers of the two together. Oxygen therapy and pulmonary rehabilitation programs are also possibilities for more moderate-severe COPD. Patients with COPD are at higher risk of exacerbation if they get the flu, so it’s necessary to get the annual influenza vaccine and to ask her PCP about the pneumonia vaccine as well. Lastly, if she experiences worsening of symptoms at any time she should follow up with her PCP or come to the ED if it’s an emergency.
PA Andrea helped me to understand my case better as a whole, aided in my presentation skills and gave me constructive feedback which I will use in the future. She quizzed me on my pharmacology cards, pushing me to know my chosen drugs well. We went through my procedure log and discussed how and where I could get more procedures done – she really cared about my learning and helped me with my overall understanding of this case!
