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

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