History 

Identifying Data: 

Full Name: S.K.

Address: N/A 

Date of Birth: N/A 

Date & Time: 03/13/2011, 1:00pm 

Location: NYPQ  

Religion: N/A 

Source of Information: Self 

Reliability: Reliable 

Source of Referral: Self 

Mode of Transport: N/A 

Chief Complaint: “I’ve been short of breath and coughing and I have chest pain” x 3 days.

History of Present Illness: 

62 y/o female, former smoker BIBEMS with PMH of COPD, HLD, HTN, GERD and asthma presents with SOB and coughing with associated substernal chest pain that progressively got worse as of 8 days ago (3/6/23). She states that she has recurrent episodes of COPD exacerbations monthly usually brought on my high temperatures in her apartment. Pt reports that she developed a cough with yellow sputum production and increased oxygen requirements. Notes that she is usually on 2 L of oxygen via nasal cannula, but had to increase it to 4 L. Pt reports that dyspnea was associated with substernal chest pain that she describes as pressure-like, worse with exertion, and not exacerbated by deep breathing or coughing and is non-radiating. Pt presented to PMD’s office and noted to have SpO2 85% on room air and was referred to ED. Pt also admits to sore throat, recently worsened bilateral lower leg edema, but denies fever, chills, fatigue or dysuria. 

Initial DDx: 

• COPD exacerbation
• Pneumonia
• ACS

Past Medical History: 

Asthma

COPD

GERD

HLD

HTN

Opioid dependence

Osteoarthritis

Pneumonia

PTSD

Sleep disorder

Childhood Illnesses- N/A 

Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent 2022) 

Screening test and results – Colonoscopy (01/23/23) – negative; Upper GI endoscopy (01/23/23) – negative 

Past Surgical History: 

C-section

Right Shoulder Replacement (1/03/22)

Denies any blood transfusions. 

Medications: 

• acetaminophen (TYLENOL) tablet 650 mg
• albuterol (2.5 MG/3ML) 0.083% nebulizer solution 2.5 mg
• amlodipine (NORVASC) 5 MG tablet 5 mg
• atorvastatin (LIPITOR) tablet 40 mg
• azithromycin (ZITHROMAX) IVPB 500 mg IN D5W 250 mL ADDV/MBP/V2B
• benzocaine-menthol (CEPACOL) lozenge 1 Lozenge
• ceftriaxone (ROCEPHIN) IVPB 1 g in 50 mL D5W (wrapper)
• enoxaparin sodium (LOVENOX) syringe 40 mg
• furosemide (LASIX) injection 40 mg
• guaifenesin-dextromethorphan (ROBITUSSIN DM) 100-10 MG/5ML syrup 10 mL
• ipratropium 0.02 % nebulizer solution 2.5 mL
• lidocaine (LIDODERM) 5 % external patch 1 Patch
• losartan (COZAAR) tablet 50 mg
• melatonin tablet 5 mg
• methylprednisolone sod suc (Solumedrol) injection 40 mg
• mirtazapine (REMERON) tablet 30 mg
• oxycodone-acetaminophen (PERCOCET) 5-325 MG per tablet 1 tablet
• pantoprazole (PROTONIX) enteric coated tablet 40 mg
• polyethylene glycol 17 gram (MIRALAX) oral packet 1 Packet
• trazodone (DESYREL) tablet 100 mg

Denies use of herbal supplements. 

Allergies: 

NKDA 

Family History: 

Mother – HTN

Dad – HTN

Aunt – HTN, HLD, CAD

Maternal/paternal grandparents – Deceased 

Family history of cancer. Denies family h/o diabetes and myocardial infarctions. 

Social History: 

Miss SK lives alone and divorced.

Habits – Admits to being former smoker and quit ~20 months ago. Smoking included cigarettes which she stared 47 years ago. Has a 11.25 pack-year smoking history. Has never used smokeless tobacco. No history of alcohol abuse, denies history of illicit substances. Denies drinking coffee. 

Travel – No recent travel. 

Diet – She states she has a well-balanced diet. 

Exercise – Denies exercise. 

Safety measures – Admits to wearing a seatbelt. 

Sexual Hx – Pt is heterosexual. 

Denies history of sexually transmitted diseases. 

Review of Systems: 

General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue. 

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 lacrimation, pruritus, visual disturbances. Does not wear glasses. Does not recall when her last eye exam was or what his visual acuity or pressure is. 

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

Nose/sinuses – Denies discharge, epistaxis, or nasal polyps. 

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

Breast – Denies lumps, nipple discharge, or pain.  

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Does not recall when last dental exam was. 

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

Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur. 

Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.  

Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.  

Menstrual/Obstetrical – Pt is post-menopausal.

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

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

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

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

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

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.  

Physical 

General: Female appears clean & casually-groomed, overweight, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. Does not appear to be in acute distress. Pt appears as stated age. 

Vital Signs: BP: (R) Seated 100/60    P:  85 beats/min, regular 

   (L) Seated 105/80  

R: 18 breaths/min, unlabored O2 Sat: 94% Nasal Cannula

T: 36.7 degrees C (oral) 

Height: 62 inches Weight: 243 lbs BMI: 44.4 

Head, Skin, & Nails 

Hair: Average quantity and distribution. Black color. Curly texture. No evidence of lice or seborrheic dermatitis. 

Skin: Warm and moist, smooth texture, good turgor.  

Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities 

Head: Normocephalic, atraumatic, non-tender to palpation throughout. 

Eye Exam 

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. 

Ear Exam 

Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU. 

Nose & Sinuses Exam 

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. 

Mouth & Pharynx 

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation. 

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.  Non-tender to  

Palpation; continuity intact.  

Teeth – Good dentition / no obvious dental caries noted.  

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation. 

Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation. 
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.  

Tonsils present with no injection or exudate. Uvula pink, no edema, lesions 

Neck Exam 

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.  

Thorax & Lungs:  

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout. 

Lungs –Wheezing present. No stridor or rhonchi. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. 

Cardiac Exam 

Heart: JVP is 2.5cm above sternal angle with the head of the bed at 30 degrees. PMI in 5^th ICS in midclavicular line.Carotid pulses are 2+ bilaterally without bruits. Irregular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.  

Abdominal Exam: Abdomen flat and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge.  

Pelvic Exam: 

Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy. 

Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault.  

Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.  

Reflexes: 

	Biceps	Triceps	Brachioradialis	Patellar	Ankle/Achilles	Babinski
Right	2+	2+	2+	2+	2+	absent
Left	2+	2+	2+	2+	2+	absent

Peripheral Vascular:  1+ bilateral lower leg non-pitting edema, but extremities are normal in color and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted. 

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema / 

ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities. 

Assessment: 62 y/o female, former smoker, with PMH of COPD, HLD, HTN, GERD and asthma presents with cough, dyspnea and associated substernal chest pain requiring increased oxygen. Will order CBC, BMP, proBNP, hepatic panel, lipase and amylase, VBG, D-dimer, troponins x2, type & screen, coags, respiratory pathogen PCR panel, EKG, and CXR. Admitted for COPD exacerbation

DDx after H&P: 

• COPD exacerbation 

Labs:  (record labs)

• BMP – unremarkable
• CBC – unremarkable
• proBNP – unremarkable
• Hepatic Panel – unremarkable
• Lipase & Amylase – unremarkable
• Type & Screen 
• Coags 
• RPR – negative
• Troponin – negative
• VBG – without hypercarbia or respiratory acidosis
• D-dimer – unremarkable

Imaging: 

• CXR –  chronic bilateral interstitial opacities lower lobes
• EKG – unremarkable

Plan: Given that patient is still experiencing dyspnea and dyspnea on exertion, will continue patient on albuterol/ipratropium nebulizer treatments every 6 hours. Will also continue Solumedrol 60mg IV BID with a slow taper. Empiric antibiotics started in ED as cannot exclude superimposed pneumonia, will continue azithromycin and ceftriaxone. Will also obtain follow up D-dimer, and if elevated consider further evaluation with CTA. Obtain pulmonology consult. To address chest pain and rule out acute coronary syndrome, will follow up with third troponin and repeat proBNP. Will also obtain Hgb A1C, lipid panel, TSH, echo and cardiology consult. Increase Lasix to 40mg IV to address lower extremity edema and follow up with Doppler for bilateral lower extremities. Patient to continue losartan 50mg PO QD, amlodipine 10mg PO QD, atorvastatin 40mg PO QD, and pantoprazole 40mg QD. Continue home meds. Discussed findings, diagnosis and treatment plan with patient. Pt understands and agrees to move forward with plan. Will re-evaluate patient’s disposition after labs, imaging and pulmonology and cardiology consult obtained.

Patient Education: Advised patient to continue with smoking cessation, to take medications and inhalers as instructed, and if symptoms worsen at home to return to the emergency room. Also advised to avoid any second-hand smoke and air pollution. Advised to get flu vaccine yearly, COVID-19 vaccine, and pneumococcal and pertussis vaccines and to stay away from other people with colds or flu and to wash hands often. Learn breathing techniques for COPD, such as pursed-lip breathing, which may help patient breathe easier during exacerbation.