Emergency Department
Patient Case Number: ED56-Stauffer, Frank
Patient Name: Frank Stauffer | DOB: 08-10-62 | Sex: M
Date of Service: 11-01-XX | Attending Physician: Paul Morrows, MD
Reason for Visit: Abdominal/Chest pain

# History of Present Illness:

Mr. Stauffer is a 52-pack year smoker and presents with a complaint of abdominal/chest pain and SOB. Patient reports onset of symptoms about 2 weeks ago. Initially started as RUQ and right lower chest pain that was pleuritic in nature and associated cough. Patient states that about 3 days ago he had argument with friend and was punched in right upper abdomen. Since then his pain has gotten significantly worse.

# Medical History: Alcohol Dependence in remission-attends AA every month

# Medications: None Surgical History: None Review of Systems:

# Constitutional: Negative for fever, chills, activity change and appetite change.

# HENT: Negative.

# Eyes: Negative.

# Respiratory: Positive for cough and SOB

# Cardiovascular: Positive for chest pain

# Gastrointestinal: Positive for abdominal pain. Negative for nausea and vomiting.

# Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative.

# Allergic/Immunologic: Negative.

# Hematological: Negative.

# Vitals:

Temperature | 98.9°F
Pulse | 110
Respirations | 18
Blood Pressure | 180/110
SpO2 | 92% on room air
Height | 6’0ft
Weight | 178lbs
BMI | 24.1

# Physical Examination:

# Constitutional: He appears well-developed and well-nourished. No distress.

# HENT:

# Head: Normocephalic.

# Mouth/Throat: Oropharynx is clear and moist.

# Eyes: Conjunctivae are normal.

# Neck: Neck supple.

# Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no friction rub. No murmur heard. tachycardia

# Pulmonary/Chest: Effort normal. Rhonchi right lower lobe Abdominal: There is Right upper and lower quadrant abdominal pain Skin: He is not diaphoretic.

Nursing note and vitals reviewed.

# MDM:

N umber of Diagnoses or Management Options

CAP (community acquired pneumonia) Chest pain, unspecified chest pain type Sepsis, due to unspecified organism

# 1) CAP/Sepsis

-3/4 SIRS (WBC 24, RR>20, HR >90)

-blood cultures sent; started on ceftriaxone and azithromycin

-patient 91 % on room air which improved to >94% on 4L NC

# CT of Chest and Abdomen IMPRESSION:

1. Loculated right pleural effusion which measures slightly higher attenuation than simple fluid in the dependent portions may represent superimposed infection, hemorrhage, or a malignant effusion. No definite evidence of empyema. Recommend correlation with thoracentesis fluid testing.

2. No acute intra-abdominal or pelvic process.

3. Multilevel degenerative disc disease as described above, most significant at L3-L4 and L4-L5 with moderate spinal canal stenosis. Patient with loculated effusion possibly para-pneumonic vs hemothorax vs malignant effusion. Patient will require diagnostic thoracentesis. Patient with total health and will likely be transferred to XYZ Hospital. Given transfer will defer thoracentesis to transfer facility given loculated effusion which may benefit from IR and expected delays in results.

A mount and/or Complexity of Data Reviewed

# Clinical lab tests: reviewed and ordered

# Radiology tests: ordered and reviewed

# Decide to obtain previous medical records or to obtain history from someone other than the patient: yes

# Review and summarize past medical records: yes

# Independent visualization of images, tracings, or specimens: yes

R isk of Complications, Morbidity, and/or Mortality

# Presenting problems: high Diagnostic procedures: high Management options: high

1. Sepsis d/t unspecified organism. Uncertain etiology and patient will require greater than 2 midnights to establish cause and manage illness.

2. CAP.

3. Alcoholism in remission.

4. Smoker

# Electronically Signed By: Paul Morrows, MD

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