Tuesday, November 29, 2005

History and Physical for Pulmonary Embolism

Chief Complaint
chest pain and shortness of breath
History of Present Illness
23 year old female with past medical history significant for birth control use of five years and 15 smoke pack years presents witch chest pain and shortness of breath. Four days prior to admission, she started to experience a dull, substernal pain with deep breaths. Two days prior to admission, she experienced shar pain in lower left anterior axillary line with deep breaths. One day prior to admission, she started to experience upper left sided chest pain. While at her Ob-Gyn office on the morning of admission, she was experiencing shortness of breath, and she was told to go to the ER. Currently, her chest pain is constant on the left side. She says she can walk ten steps before becoming short of breath. She denies palpitations, leg pain, nausea, vomiting, diarrhea, cough, pain radiation. Previously, she experienced chest pain during this current summer which went away in four days without hospital admission.
Past Medical History
Patient denies hypertension, diabetes, stroke, coronary artery disease, rheumatic fever, asthma, or spontaneous abortions. Patient has been on Depo-provera for five years prior to current birth control of Norgestrel.
Past Surgical History
Patien did not have previous surgeries.
Patient has not received her pneumococcal, hepatitis, or flu vaccine.
Family History
Father is alive, 52 years old without hypertension, diabetes, coagulopathy, or coronary artery disease. Mother is alive, 46 years old. She has hypertension. She has no history of coronary artery disease, coagulopathy, or diabetes.Both grandmothers had strokes at old ages. Her family has no history of cancer or coagulopathy.
Social History
Alcohol - She drinks up to 12 beers during the weekend over one to two nights.
Tobacco - She has been smoking 1.5 packs per day for 10 years
Substance - She denies any substance abuse.
Psychosocial - She denies any changes in her general behavior. She lives with her friend after leaving her family residence.
Functional - She believes she has normal function.
Review of Systems
General: () weight loss () fever () night sweats () weakness/fatigue () appetiteEndocrine: () heat intolerance () decreased energy () thyroid/reanl dz () polydipsia () polyuriaLympatics: () lymphadenopathySkin: () itching () pale () palmar creases Hematology: () anemia () bruising () bleedingHead: () seizures () trauma () loss of conscioussness () headache () vertigo () dizzinessEyes: () visual changes (X) blurred vision () loss of vision () dischargeEars: () discharge () ear pain () tinnitus () ototoxic drug history () hearing lossNose: () discharge () rhinorrhea () epistaxisMouth and Throat: () lip cracking () gum soreness () gum hypertrophy () dryness () thirst () excessive salivation () throat pain () hoarsenessCardiorespiratory: (X) SOB () valvular disease (X) orthopnea (X) dyspnea on exertion () nocturia () edema (X) paroxysmal nocturnal dyspnea () cough () cyanosis () hemoptysisGastrointestinal () dysphagia () abdominal pain () vomiting () hematemesis () melena () hematochezia () change in appetite () diarrhea () constipation () jaundiceGenitourinary: () change in bladder function () change in amount () dysuria () hematuria () dischargeNeuropsychiatric: () weakness () motor/sensory deficit () depression () anxietyPain: Chest pain on left side
Physical Exam
General Appearance:Vital Signs:Temperature: 98.1 F Oxygen Saturation: 100% on RA Blood Pressure: 125/82 Respiratory Rate: 18 Pulse Rate: 117Skin/Nails:Head:Eyes:Ears:Nose:Throat/Mouth:Neck:Lymph:Pulmonary: CV:Abdomen:Breasts:Rectal:Genitals:Peripheral pulses:Musculoskeletal:Neurologic:Mental StatusCN ICN IICN III,IV, VI CN V, VIICN VIICN VIIICN IX, XCN XICN XIICerebellarDTRs
Troponin I <0.05,>D-Dimer 3.20
CT - Multiple pulmonary embolisms on the right upper lobe, right lower lobe, left upper lobe, and left lower lobe in the segmental and subsegmental branches. Her right middle lobe does not have a pulmonary embolism.
PT: 13.7 PTT: 30
INR: 1.05

23 year old female with a past medical history significant for smoking and contraceptive use presenting with multiple, acute pulmonary embolisms. She presented with some classic signs of pulmonary embolism including dyspnea and chest pain (1).

1. Tierney, Lawrence M., ed. Current Medical Diagnosis & Treatment. 44th ed. New York: McGraw Hill, 2005.

Created with H and P

Wednesday, November 23, 2005

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Tuesday, November 08, 2005

Chronic Diarrhea

  • Secretory Causes
  • Medications
  • Bowel Resection, Mucosal Disease, Enterocolic Fistula
  • Hormones

    • Carcinoid Tumor
    • Serotonin
    • Histamine
    • Prostaglandins
    • Kinins
    • Gastrinoma
    • VIPoma
    • Calcitonin
    • Somatostatinoma

  • Congenital Defects in Ion Absorption
  • Osmotic Causes
  • Osmotic Laxatives
  • Carbohydrate Malabsorption
  • Steatorrheal Causes
  • Pancreatic Exocrine Insufficiency

    • Chronic Pancreatitis
    • Cystic Fibrosis
    • Pancreatic Duct Obstruction

  • Mucosal Malabsorption

    • Tropical Sprue
    • Whipple's Disease
    • Abetalipoproteinemia
    • Medications - colchicine, cholestyramine, neomycin
    • Chronic Ischemia

  • Postmucosal Lymphatic Obstruction
  • Inflammatory Causes
  • Idiopathic Inflammatory Bowel Disease
  • Eosinophilic Gastroenteritis

Saturday, November 05, 2005

History and Physical for SOB

Informant: Patient - mostly reliable
Age: 79 Sex: Male

CC: Chest pain, SOB for one day
Reason for Admission: Chest pain, SOB for one day

HPI: 79 yo AAM c right sided CP, not radiating, sharp, pleuritic, no aggravating or relieving factors. CP accompanied with SOB with acute to sub-acute onset. Pt has cough producing whitish sputum. He has chills, and currently, the patient is feeling better than last night.

Glaucoma BL
Immunizations - he recieved his pneumo and flu vaccines last year.

Fem-Pop bypass on left leg

Injuries/Disabilities: none

Lovastatin 20 mg PO qday
Lasix 20 mg PO qday
Prednisone 5 mg PO qday
Lasix 40 mg PO qday PRN edema
Calcium 600 mg PO bid

Pneumo and Flu received in 2004

Family History:

Social History:
lives alone
past smoker for 50 years
past etoh

Review of Systems:
nausea, vomiting 2-3 times, no change in bowel movements, no dysuria

Physical Exam:
VS: Temp-101.5 BP-127/70 HR-90 Pulse Ox 80s in Er, currently went from 90 to 99, 101.5 degrees
Gen: mildly tachypnic, AO*3
HEENT: -JVD, carotid pulse- 2+ with no bruits, PERRL
Chest: CTA BL, -w/c/r
CVS: irregular rhythm, SEM II/VI
Abdomen: NT/ND, soft, +BS
Ext: -edema. -DP, Left calf tenderness
Neuro: no focal deficits present

CXR - Infiltrates R side and base

Na - 140
K - 4.1
Cl - 101
CO2 - 29
BUN - 14
Cr - 1.0
Glucose - 137
Ca - 8.4
WBC - 11.4
HGB - 13.2
HCT - 39.3
PLT - 268
MCV - 81
EKG - freq PACs, LAD, Q waves in V2-V3, TWI in V1
CKMB - 1.3
Myoglobin - 142
Troponin - 0.05

79 yo AAM presented with intermittent SOB and chest pain on right side.

Problems List:
1. SOB
2. Chest pain

Differential Diagnosis:
1. COPD exacerbation - can present with cough, sputum production, and SOB.
2. Pulmonary Embolism - Pain in left calf could be a sign of a DVT and subsequent clot could have moved to the lungs. This could have caused the current symptoms of SOB and chest pain.
3. Pneumonia - CXR infiltrates, SOB, and chest pain can be from a community acquired pneumonia. Possible organisms include Streptococcus pneumoniae, Haemophilus influenza, Mycoplasma pneumoniae, Chlamydia pneumoniae, Staphylococcus aureus, Neisseria meningitidis, Moraxella catarhallis, and Klebsiella pneumoniae.
4. Sarcoidosis - a sarcoid inflammation of the lung can present with malaise, fever, and dyspnea. No hilar lymphadenopathy was present on CXR. No other findings of sarcoidosis were present: erythema nodosum, parotid gland enlargement, hepatosplenomegaly, and lymphadenopathy. Symptoms referable to other organs were not present either.
5. MI - a myocardial infarction can present with chest pain and SOB. The patient's location of pain on the right side, and lack of radiation make this less likely. His cardiac chemistry levels were well within normal limits.

Diagnostic Plan:
1. CT angio scan of chest
2. Pulmonary function tests
3. Pulse oximetry
4. Consult pulmonology

Therapeutic Plan
1. DVT prophylaxis
2. Heparin qtt
3. Antibiotics - Zithromax 500mg IV qday
4. O2 support 2L
5. Steroids

History and Physical for Sickle Cell Crisis

H and P SC Crisis

Informant: Patient - reliable
Age: 43
Sex: M

CC: pain in head, neck, arms, stomach, and legs
Reason for Admission: pain in head, neck, arms, stomach, and legs

History of Present Illness:
Patient 43 yo AAM presented with pain in arms, back, stomach and legs which started yesterday morning. His last crisis was 2-3 years ago. It is well localized to the areas mentioned. He tried using Percocet and Oxycontin but they were ineffective in controlling his pain. He also complains of a productive cough with yellow phlegm for 2-3 weeks. He had no associated chest pain. He had no nasal congestion, but he did have post nasal drip. He has no nausea, vomiting, diarrhea, fever or chills.

Past Medical History:
Sickle Cell Disease (SC) diagnosed at age 12. Not significant for any other chronic conditions such as diabetes or hypertension.

Past Surgical History:
No surgical history.

Injuries/Disabilities: Considers SC a disability.
Oxycontin 80 mg po bid
Percocet 5 mg 1-2 tablets q 4-6 hours prn pain
Folic Acid 1mg po qday

Herbal Meds: none
Immunizations: Pneumo and flu vaccines up to date since last year
Allergies: hay
Drugs: Morphine - lack of coordination, nervous; toradol - lack of coordination
Food: none
Family History:
Mother has sickle cell disease and diabetes. His family has no history of hypertension, cancer, cardiac diseases, or thalassemia.
Social History:
He lives in an appartment with his fiance. He's currently unemployed due to his sickle cell disability. He has no history of alcohol abuse. He smokes 3-4 cigarettes per day.

Review of Systems:
Summary: - f/c, -n/v/d, -dysuria, + cough for 3 weeks, - rhinorrhea, - headache

Physical Exam
General Appearance: Pt in acute distress from pain
Vital Signs:
Temperature: 96.7 F Oxygen Saturation: 98% Room Air
Blood Pressure: 100/46
Respiratory Rate: 16 Pulse Rate: 68
Skin/Nails: no clubbing
HEENT: PERRL, clear nasal turbinates, non-erythematous pharynx, no thyroid enlargement, no lymphadenopathy
Pulmonary: CTA BL, -w/c/r
Abdomen: soft, NT, ND
Peripheral pulses: 2+ DP
Musculoskeletal: pain in both arms, legs, and neck
CXR - clear and normal

WBC 18.4
HGB 7.3
HCT 21.8
PLT 482
Na 138
K 4.7
Cl 108
CO2 26
Cr 0.6
Glucose 81
Ca 8.4
Retic 8.71
Retic Index 8.9

Assessment: 43 yo AAM with sickle cell crisis in arms, legs, neck, and head.

Problem List:
1. sickle cell crisis
2. increased white count

Differential Diagnosis:
He's presenting with acute onset of pain which is most likely related to a sickle cell crisis. He presents with no other signs, symptoms, or lab values suggesting other etiologies such as acute rheumatic fever, osteoid arthritis, or any other polyarticular arthritis. His pain is spread throughout his bones and joints which makes an SC crisis more likely.
His white blood count could be due to an infection, but he is not presenting with fever or any inflammatory reaction symptoms. He has no tachypnea, but he does have upper respiratory infection symptoms. His pulse ox is normal. His CXR is clear and this does not appear to be pneumonia. He should be worked up with urine cultures, urine analysis, and blood cultures.
Diagnostic Plan:
1. CBC w diff
2. Screen 8
3. Retic count and Retic Index
4. Blood Cx
5. Urine Cx
6. Urine Analysis
Therapeutic Plan:
1. Dilautid 4mg IV q4h
2. 125 cc/hr D5W

Causes of Chest Pain

Chest Pain

  • pulmonary embolus
  • pleuritis
  • pneumothorax
  • COPD
  • Gastroesophageal Reflux Diseases (GERD)
  • esophageal ulcer
  • peptic ulcer disease
  • Boerhaave's syndrome
  • Mallory Weiss Tear




  • myocardial infarction
    • ST elevation MI
    • non-ST elevation MI
  • Angina
    • stable angina
    • unstable angina
  • pericarditis
  • tamponade
  • myocarditis