Identifying Data:

Name: Mr. G

Sex: Male

Address: Queens, NY

Date of Birth: 2/26/41, 80 years old

Date & Time: 4/21/21, 10:00 AM

Location: New York Presbyterian Hospital, Queens, NY

Religion: Christian

Marital Status: Married

Race: African American

Source of Information: Self

Reliability: Reliable

Source of Referral: Self, PCP Dr. Kirschbaum

Mode of Transport: Ambulance

Chief Complaint: “Coughing and SOB” x 2 weeks

History of Present Illness:

80 y/o married, African American male, at baseline, who ambulates on his own, independent in ADL’s and most of IADLs, and lives at home with his wife and daughter, with pmhx of asthma, HTN, HLD, GERD, bronchiectasis, gout, prostate cancer, s/p radiation, presented to NYPQ ED on 4/19 c/o 2 weeks of SOB and productive cough with yellowish sputum, that has gradually worsened over the past few days. He had his 2nd dose of pfizer vaccine 2 weeks ago.  He states the cough is on and off, is aggravated by hot liquids such as coffee and alleviated by voice rest and taking slow sips of water, and causes him to lose control of his bladder and leak urine. Patient states he has been using his inhaler but with minimal improvement, and rates the severity of the cough as 10/10. He states he has asthma exacerbations every few months, which usually just improves with inhaler use, and was admitted one other time with similar symptoms about 5 years ago. 

In ED, patient tested negative for covid, CXR showed mild bilateral interstitial opacities which are nonspecific however can be seen with atypical infection including covid. Patient afebrile. Patient was hypoxic in ED saturating at 88% on RA. He was also noted to be wheezing and using accessory muscles. He was given dexamethasone 10mg IV push in ED and 3 albuterol nebulizer treatments, and was placed on 3 L nasal cannula. Patient was admitted for asthma exacerbation. Patient admits to rhinorrhea and occasional sneezing. He denies chest pain, nausea/vomiting/diarrhea, fever/chills, dizziness, or sore throat. 

When evaluated on 4/21 in the internal medicine unit, patient stated he is feeling much better. He stated he still has a slight cough that is non-productive, rating the severity as 5/10, as well as some rhinnorhea and nasal stuffiness, but denied SOB, sating at 96% on 2L nasal cannula. Patient also denied current chest pain, dyspnea/doe, n/v/d, fever/chills, dizziness, or sore throat.

Past Medical History:

Present medical illnesses – Asthma, HTN, HLD, GERD, Bronchiectasis, Gout

Past Illnesses- Prostate Cancer, in remission s/p radiation since last March

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

Bilateral Cataract Surgery, June 2010

Home Medications:

1. Albuterol .083% and Ipatropium 0.5 mg Solution for nebulization, 1amp, inhalation q6h, for asthma and bronchiectasis
2. Montelukast 10 mg tab, PO, qd, for asthma
3. Tiotropium Inhalation, 18 microgram 1 capsulation, inhalation, qd, for asthma
4. Amlodipine 5mg tab, PO, qd, for HTN
5. Pravastatin 20 mg tab, PO, qd, for HLD
6. Allopurinol 100 mg, PO, qd, for Gout
7. Famotidine 40 mg, PO, qhs, for GERD

Patient states he is compliant with medications.

Additional Hospital Medications:

1. Enoxaparin 40 mg Sc injection, qd, for DVT prophylaxis
2. Methylprednisolone Sodium 40 mg IV push, q6h

Allergies:

Shellfish, gets rash all over body 

No drug or environmental allergies

Family History:

Mother – deceased at age 91, natural causes

Father – deceased at age 82, Cardiovascular disease

Son- 53, ESRD s/p second kidney transplant 2 weeks ago

Son- 51, Alive and Well

Daughter- 50, Alive and Well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mr. M is a married male, living at home in a 2 story house with his wife and daughter. He is able to ambulate around the house well. He previously worked at Metropolitan Lumber and Hardware and retired last year. 

Habits – Patient drinks one cup of coffee in the morning and a cup of tea at night. Admits to drinking 4-5 alcoholic drinks a year. Admits to past smoking 12 pk/yrs, quit 50 years ago. Denies use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to sleeping well, for about 8 hours every night.

Exercise – States that he does not regularly exercise or engage in physical activity.

Diet- Patients maintains a balanced diet, eats eggs and bacon in the morning, 2 yogurts throughout the day, and “whatever my wife makes” for dinner.

Sexual History: Monogamous with female partner. Currently sexually active. Denies history of sexually transmitted infections.

Activities of Daily Living: Independent

Independent Activities of Daily Living: Has help from daughter

Advanced Directives: Full Code

Review of Systems:

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

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, lightheadedness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Patient had bilateral cataract surgery in June 2010, admits to current use of reading glasses. Denies use of contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam 2 years ago with Dr. Lerner- normal.

Ears –Admits to occasional tinnitus. Denies ear pain, discharge, difficulty hearing, or use of hearing aids.

Nose/sinuses – Admits to rhinnorhea, and nasal stuffiness. Denies nasal obstruction or epistaxis.

Mouth/throat – Denies use of dentures, sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. Last dental exam last year-normal. 

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

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to cough, wheezing, asthma, dyspnea, and SOB. Denies orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

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

Gastrointestinal system – Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system – Admits to urinary frequency, urgency, and nocturia. Denies polyuria, oliguria, incontinence, dysuria, hesitancy, dribbling, or flank pain.

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

Nervous System–Denies seizures, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, numbness, decreased sensation, or asymmetric weakness.

Peripheral vascular system –  Admits to varicose veins and occasional peripheral edema on bilateral calves for the past 10 years. Denies intermittent claudication, coldness or trophic changes or color changes.

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

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

Psychiatric – Denies feelings of depression, anxiety, OCD or ever seeing a mental health professional.

Physical Exam

General: 80 year old male, alert and oriented to person, place and time. Patient is of average build and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 152/68 left arm seated     

R: 18 breaths/min unlabored     

P:93 beats/min, regular       

T: 36.5 Degrees C (oral)                      

O2 Sat: 96% on 2 L Nasal Cannula

Height: 73 inches                    Weight: 182 pounds               BMI: 24.0

Skin- Warm and moist, smooth, good turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout fingrs and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear.  Visual fields full OU. PERRL, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Whisper test shows auditory acuity intact.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. 

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips -Pink and moist; no cyanosis or lesions

Mucosa – Pink,No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. 

Teeth – Good dentition, missing front 2 teeth. Last dental exam 1 year ago.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   

Thyroid- Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Diffuse wheezing and rhonchi appreciated upon auscultation bilaterally, hyperresonance to percussion bilaterally, decreased tactile fremitus. Chest expansion and diaphragmatic excursion symmetrical. 

Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Male Genitalia- deferred

Anus, Rectum, and Prostate-deferred

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment in his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Cranial Nerve Exam: 

CNII-visual fields full by confrontation, red reflex present

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities, no rigidity or crepitus noted. Symmetric muscle bulk, slight atrophy, no tics, tremors or fasciculation. Strength 5/5 throughout upper and lower extremities.  Romberg negative, no pronator drift noted, gait steady with no ataxia. Tandem walking and hopping shows balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes-2+ throughout.

Peripheral Vascular Exam- Some palpable cords and varicose veins on lower extremity bilaterally. Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Labs:

ABG

Chloride- 105

pH- 7.36

pCO2- 42.7

pO2- 108

HCO3- 23.7

Chemistries:

Na- 136

K- 4.6

Cl- 99

CO2- 27

BUN- 26.3 (slightly high)

Cr- 1.03

BUN/Cr Ratio- 26 (slightly high)

Ca-9.5

Mg- 2.2

P- 3.8

Anion gap-10

Glucose-96

Liver Function Tests:

Protein-7.6

Albumin-4.6

Globulin- 3.3

AST- 23

ALT- 13

Alk Phos- 75

Bilirubin- 0.7

Cardiac Markers

Troponin- <0.010

CRP- <0.30

Pro-BNP- 26

Hematology

WBC-8.561

Hemoglobin-15.1

Hematocrit- 48.1

Platelets- 223

MCV- 88.5

MCH- 26.4

RBC- 5.0

Differential

Total Cell Count- 115

Lymphocyte-28.00

Monocyte-8.00 (high)

Eosinophil- 19.00 (high)

Segmented Neutrophils- 45.00

Influenza A, B Virus RNA negative, COVID PCR Test negative

Imaging:

EKG- Sinus Rhythm, High voltage in limb leads

Abnormally high Lewis Index

LEFT VENTRICULAR HYPERTROPHY

ST-T abnormality in the lateral leads

THIS ABNORMALITY MAY BE DUE TO HYPERTROPHY AND/OR ISCHEMIA

Summary: ABNORMAL ECG

XR Chest 2 Views- Mild bilateral interstitial opacities which are nonspecific however

can be seen with atypical infection including Covid.

CT Chest w/o Contrast- Moderate to severe bronchiectatic changes, probable mucus plugging and airways inflammation in the mid and lower lung zones, demonstrating interval progression since the prior CT of 10/09/2010.

Assessment:

80 y/o married, African American male with pmhx of asthma, HTN, HLD, GERD, bronchiectasis, gout, prostate cancer, s/p radiation, presented to NYPQ ED on 4/19 c/o 2 weeks of dyspnea on exertion, productive cough with yellowish sputum, that has gradually worsened over the past few days. Was placed on 3 L nasal cannula and given dexamethasone and albuterol nebulizer treatments in ED and admitted. Currently sating at 96% on 2L NC, still has diffuse wheezing and rhonchi and slight cough, but feeling much better.

Differential Diagnoses

1. Pulmonary Embolism- has SOB, cough, low O2 saturation upon arrival to ED (88%), recently received a second dose of Pfizer vaccine and still unknown side effects. However, O2 conc is normal on ABG, CXR and other symptoms lead towards other diagnoses. D-dimer and CTPA not performed.
2. Asthma/ Bronchiectasis Exacerbation- patient has asthma and has had asthma exacerbations like this before, has productive cough and wheezing that improved s/p dexamethasone and nebulizer, hyperressonance to percussion and decreased tactile fremitus, CT scan shows mucous plugging. Also has elevated eosinophils which could be due to asthma/allergies
3. COVID-19 Pneumonia- has SOB, cough, wheezing, CXR had infiltrates suggestive of COVID-19 PNA. However, just received 2nd Pfizer vaccine and COVID test was negative.
4. Acute Bronchitis- has cough and SOB, cough produced yellow mucus.
5. LVH-has SOB, EKG shows signs of LVH, BP is high. However, no sign of LVH on CXR.
6. Bacterial Pneumonia- has bronchiectasis which predisposes to pna, and has cough producing green sputum, SOB, and rhinitis, indicating infection. However, no fever, and WBC/neutrophil count is not elevated, which decreases likelihood bacterial infection.
7. Lung Cancer- Has cough, smoked in past, has elevated eosinophils which could indicate cancer. Also recently had prostate cancer which could have metastasized to lungs. However, prostate cancer metastasis to lungs is rare, no other signs of cancer, such as hemotpysis, fatigue, weight loss 
8. Tuberculosis- has cough and elevated monocyte % which could indicate Tb. However, denies hemoptysis, fever, chills, night sweats, or weight loss, cxr is not indicative of tb.

Plan:

1. SOB-on supplemental o2, 2L nc currently sating at 96% s/p steroids and albuterol nebulizer, was initially 88% on RA in ED, afebrile, pro-BNP low

CXR – mild b/l interstitial opacities seen atypical infection like COVID-covid test neg x 1,  vaccinated , 2nd dose of pfizer 2 weeks ago, -repeat covid test 24 hrs from now

CT lung: Moderate to severe bronchiectatic changes, probable mucus plugging and airways inflammation in the mid and lower lung zones, demonstrating interval progression since the prior CT of 10/09/2010.

-continue bronchodilator and steroids

-f/u d-dimer, CTPA to r/o PE, pct, esr, crp to r/o infectious process

• Cough/ Wheezing/ Rhinnorhea- improving but not completely better, prescribe cough suppressant q4-6 hours

-trend WBC’s, pct, esr, crp to r/o infectious process, f/u sputum sample to r/o tb

• LVH on EKG- evaluate further with repeated EKG, Echo

• Elevated BUN/ BUN/CR ratio- only elevated slightly, likely due to aging/ dehydration. Trend to ensure not worsening.

• Elevated Monocyte and Eosinophil %- likely due to asthma exacerbation. Continue trending to ensure not increasing

• Asthma/ Bronchiectasis- appears to be generally controlled, but currently experiencing what seems like asthma exacerbation. Re-evaluate medications and consider step-up in medications.

• HTN- Still high, not fully controlled with current medications. Consider increasing dose or adding additional medication.

• Varicose Veins- not direct issue but veins are palpable and admits to leg swelling occasionally. Encourage exercise, leg elevation, compression stockings.

• Urinary frequency, urgency, and nocturia- likely due to h/o prostate cancer or aging. Consider adding anticholinergic medication to help with symptoms 

1. HLD- no acute symptoms. Check Lipid panel to ensure it is well controlled on current medication.

1. GERD- well-controlled, no acute symptoms, continue current medication.

1. Gout- well-controlled, no acute symptoms, continue current medication.