Demographics:
Name: NS
Age: 46
Location: Queens
Source: self
Preferred Language: English
CC: Shortness of breath
HPI: Mr. NS is a 46 y/o male with no PMHx and a current smoker with a 15 pack year history who presents to the E.D. for a productive cough x 1 week associated with 1 day of acute onset of shortness of breath. He was given 1 dose of albuterol by EMS which he states helped relieve his shortness of breath a little. Activity makes his shortness of breath worse. He states his cough is worse in the morning when he wakes up and at bedtime. He admits he received 2 doses of the Pfeizer Covid Vaccine in May and denies a history of asthma, fever, chills, nasal discharge, chest pain, hemoptysis, leg pain, or recent travel.
Past medical history: none
Past surgical history: none
Past family history: unknown
Vaccinations: Childhood vaccinations up to date. Pfeizer Covid Vaccine 2 doses May 2021.
Medications: none
Allergies: No known drug, food or environmental allergies.
Social History:
Smoking: 15 pack years
Alcohol use: none
Illicit drug use: none
Review of Systems:
General: Denies night sweats, changes in appetite, weakness and recent weight gain or loss.
Skin, Hair, Nails: Denies bruising, rashes/moles, pruritis
Ears: Denies deafness, tinnitus, ear pain.
Nose/sinuses: Denies epistaxis or obstruction.
Mouth and throat: Denies bleeding gums, sore throat, sore tongue, mouth ulcers. Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary System: Denies cyanosis.
Cardiovascular System: Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, or syncope.
Gastrointestinal System: Denies abdominal pain, diarrhea, constipation, or hematochezia.
Genitourinary: Denies nocturia, urgency, oliguria or polyuria.
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral Vascular System: Denies intermittent claudication coldness, varicose veins, peripheral edema or color change.
Hematologic System: denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE.
Endocrine System: Denies polydipsia, polyphagia, polyuria, heat or cold intolerance, goiter or hirsutism.
Nervous System: Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesia, hyperesthesia), ataxia, loss of strength, changes in cognition/mental status/memory or weakness.
Psychiatric: Denies anxiety and suicidal ideation.
Physical Exam:
Vitals:
BP: 152/ 107 left arm seated
Pulse: 82 regular
Respiratory rate: 17 breaths per a minute
Temperature 36.6 °C (oral)
SpO2: 87% (room air)
Weight: 68 kg
Height: 171 cm
BMI: 23.3 kg/m2
General: Alert, awake and oriented x 3. In mild acute distress, sitting up in bed.
Skin: Warm and moist, no cyanosis or rashes noted.
Hair: Average quantity and distribution.
Head: Non-tender, atraumatic, no deformities noted.
Eyes: PERRL, sclera white, conjunctiva clear, extraocular movements intact.
Ears: Non-erythematous, no discharge. Tympanic membrane visible with cone of light at 5 o’clock AD and 7 o’clock AS.
Nose: no discharge noted
Mouth: Lips moist, and pink. Mucosa, gingivae and palate pink and well hydrated without deformities. Good dentition. Uvula rises midline, tongue pink and non-deviated.
Neck: Trachea midline. 2+ carotid pulses. No adenopathy noted. Non-tender.
Thyroid: No palpable masses, not enlarged.
Chest: No signs of accessory muscle use, rises symmetrically. Non-tender to palpation.
Lungs: Wheezes present bilaterally in mid lungs. No rales or rhonchi noted. Breath sounds equal bilaterally.
Heart: Regular rate and rhythm. S1 and S2 present. No murmurs noted.
Abdomen: Non-distended. No masses, lesions, or scars. Soft non-tender with normoactive bowel sounds in all four quadrants.
Extremities: No deformities, edema, or tenderness. Full range of motion with equal pulses in upper and lower extremities.
Neurological: Cranial nerves grossly intact. Strength and sensation grossly intact.
Labs/imaging:
| CBC W/ PLATELETS+ DIFF (COMPLETE) | Status: Final |
| Value Range White Blood Cell 11.96 (H) 4.80 – 10.80 K/uL Red Blood Cell 5.72 4.50 – 5.90 M/uL Hemoglobin 16.9 13.3 – 17.7 g/dL Hematocrit 50.1 (H) 40.0 – 50.0 % Mean Cell Volume 87.6 80.0 – 100.0 fL Mean Cell Hemoglobin 29.5 26.0 – 34.0 pg Mean Cell Hemoglobin Concentration 33.7 31.0 – 37.0 g/dL Red Cell Diameter Width 12.6 11.5 – 14.5 % Platelet 236 150 – 400 K/uL Mean Platelet Volume 9.5 8.0 – 11.0 fL Absolute NRBC 0.00 0.00 – 0.00 x10(3)/uL Nucleated RBC Auto 0.00 0.00 – 0.00 /100 WBC’s |
| AUTO DIFFERENTIAL | Status: Final |
| Value Range Neutrophil Automated 69.0 37.0 – 80.0 % Lymphocyte Automated 18.70 15.00 – 40.00 % Monocyte Automated 9.0 3.0 – 10.0 % Eosinophil Automated 2.00 0.00 – 5.00 % Basophil Automated 0.60 0.00 – 1.00 % Imm Gran % 0.70 0.00 – 1.00 % Absolute Neutrophil Count 8.25 1.80 – 8.50 K/uL Absolute Lymphocyte Count 2.24 0.80 – 3.50 K/uL Absolute Monocyte Count 1.08 (H) 0.20 – 0.90 K/uL Absolute Eosinophil Count 0.24 0.00 – 0.60 K/uL Absolute Basophil Count 0.07 0.00 – 0.30 K/uL Imm Gran Abs 0.08 0.00 – 0.10 |
| BASIC METABOLIC PANEL | Status: Final |
| Value Range Sodium Level 139 136 – 145 mmol/L Potassium Level 4.2 3.5 – 5.1 mmol/L Chloride Level 101 98 – 107 mmol/L Carbon Dioxide 23 22 – 29 mmol/L Blood Urea Nitrogen 8.2 6.0 – 20.0 mg/dL Creatinine 0.74 0.70 – 1.30 mg/dL Glucose Level 105 74 – 106 mg/dL Anion Gap 15 5 – 17 Calcium Level Total 9.7 8.6 – 10.4 mg/dL BUN/Creatinine Ratio 11 10 – 20 |
| ESTIMATED GLOMERULAR FILTRATION RATE | Status: Final |
| Value Range Higher GFR estimate (approximate) >90 |
| HEPATIC FUNCTION PANEL | Status: Final |
| Value Range Protein Total 7.7 6.4 – 8.3 g/dL Albumin Level 5.0 3.5 – 5.2 g/dL Globulin 2.7 1.5 – 3.8 g/dL Bilirubin Total 0.6 0.0 – 1.2 mg/dL Bilirubin Direct 0.1 0.0 – 0.3 mg/dL Bilirubin Indirect 0.5 0.0 – 0.9 mg/dL Aspartate Aminotransferase 23 5 – 40 U/L Alanine Aminotransferase 19 5 – 41 U/L Alkaline Phosphatase 69 40 – 130 U/L |
| LIPASE | Status: Final |
| Value Range Lipase Level 18 13 – 60 U/L |
| ACTIVATED PTT | Status: Final |
| Value Range Activated Partial Thromboplastin Time 29.9 26.6 – 36.5 second(s) |
| PROTHROMBIN TIME – INR | Status: Final |
| Value Range Prothrombin Time 10.6 10.0 – 13.0 second(s) Comments: The presence of Direct Thrombin Inhibitors (Argatroban) may falsely increase results. International Normalization Ratio 0.92 0.87 – 1.13 |
| SARS-COV-2 NAAT | Status: Final |
| Value Range SARS-CoV-2 NAAT Not Detected Not Detected |
| TROPONIN T Troponin-T <0.010 PROCALCITONIN Procalcitonin 0.06 XR Chest Standard (PA, Lat) | |
NT-PROB-TYPE NATRIURETIC PEPTIDE
NT-proBeta-Natriuretic Peptide 33
| Chest X-ray Narrative & Impression INDICATION: R06.02: Shortness of breath COMPARISON: None. TECHNIQUE: PA and lateral views of the chest. FINDINGS: Lines/Tubes/Devices: None. Lungs: No evidence of acute, confluent airspace infiltrate or consolidation. No pleural effusions. No pneumothorax. Cardiomediastinal Silhouette: Cardiac silhouette size is within normal limits. Bones: Junctional spine vertebral body moderate anterior compression deformity, age-indeterminate. Upper lumbar mild retrolisthesis. Miscellaneous: The visualized soft tissues are unremarkable. IMPRESSION: No evidence of acute, confluent airspace infiltrate or consolidation. Age-indeterminate thoracolumbar junctional vertebral body moderate anterior compression deformity. CT Angiography Chest with IV Contrast Status: Final Narrative & Impression CLINICAL INDICATION: 46 years-old Male patient. R06.02: Shortness of breath COMPARISON: None. TECHNIQUE: CT angiogram of the chest was performed with thin axial sections. 100 mL of Intravenous contrast was administered. Multiplanar reformations were performed. 3-D post processing of the raw data was then performed on an independent workstation to generate the 3-D volume renderings. This CT exam was performed using one or more of the following dose reduction techniques: Automated exposure control, adjustment of the mA and/or kV according to patient size, or use of iterative reconstruction technique. FINDINGS: * HARDWARE/PROCEDURES: None. * LOWER NECK/THYROID : No abnormal mass or fluid collection. * VASCULAR : No aortic aneurysm. No evidence of pulmonary embolism. * CARDIO: Normal size. No pericardial effusion. * HILUM AND MEDIASTINUM : Enlarged right hilar lymph nodes measuring up to 1.9 cm transaxial short axis. Enlarged left hilar lymph node measuring 1.2 cm in transaxial short axis. Enlarged right paratracheal and subcarinal lymph nodes measuring up to 1.4 cm in transaxial short axis. * TRACHEA AND MAIN BRONCHI: Dependent tracheal secretions. The visualized trachea and bilateral mainstem bronchi remain patent. * LUNG PARENCHYMA : Right middle lobe perihilar 1 cm bleb. Left lower lobe lateral basal punctate calcified granuloma. * PLEURA : No effusion or pneumothorax. * AXILLA: No enlarged lymph nodes. * UPPER ABDOMEN : Left hepatic lobe 1.6 cm probable cyst. * MUSCULOSKELETAL : Exaggerated thoracolumbar kyphosis. Age-indeterminate moderate T11, mild T12 and mild L1 vertebral body anterior compression deformities. Mild L1/2 and L2/3 retrolisthesis. Otherwise mild degenerative changes of the visualized spine. * OTHER : Superficial chest wall appears unremarkable. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Bilateral hilar and mediastinal lymphadenopathy. 3. Tracheal secretions. Clinical correlation with pulmonary hygiene is recommended. 4. Age-indeterminate moderate T11, mild T12 and mild L1 vertebral body anterior compression deformities. 5. Additional findings as above. Variant DetailsLab and Collection DetailsRouting DetailsResult History |
Assessment/Plan:
Mr. NS is a 46 year old male with no PMHx and 15 year pack history who presents with a productive cough for 1 week and shortness of breath for 1 day.
Likely COPD exacerbation, never diagnosed: treat with ipratropium bromide/albuterol inhaled 0.5mg/2.5 mg per 3 mL NEB QID
Methylprednisolone sod suc injection 40 mg every 12 hours x 6 doses.
Nicotine 14mg/24 external patch 1 patch x 30 days
Obtain ABG
Hypoxia with O2 sat at 87% on room air: place on 5 L oxygen via nasal canula. Maintain O2 sat between 88% – 92% on room air.
Admit for further hypoxia workup likely in the setting of undiagnosed COPD.
Counselled on smoking cessation
