Emergency Department
Patient Case Number: ED11-Barrett, Beryl
Patient Name: Beryl Barrett | DOB: 04-22-59 | Sex: F
Date of Service: 09-02-XX | Attending Physician: Marilyn Carol, MD
Reason for Visit: Dyspnea

# Chief Complaint: Dyspnea

# History of Present Illness:

This patient presents to emergency department with a 2-week history of worsening shortness of breath. The patient’s symptoms started 2 weeks ago and she has been seen by her PCP twice. During which, she was treated with oral prednisone and IM Rocephin, however, her symptoms have been persistent and she ultimately came to emergency room for evaluation.

The patient reports that she has persistent shortness of breath with cough. No sputum. She feels she is warm at night. but she did not measure her temperature. She does not describe any chest pain. There was no wheezing. The patient is known to have COPD and is dependent on 2 L home oxygen.

# Review of Systems:

No abdominal pain. No constipation. No diarrhea. No blood in stool. No vomiting blood. No dysuria. No urgency. No frequency. All other systems have been reviewed and were found negative for 11 systems apart from history of present illness.

# Past Medical History: Significant for COPD, asthma, and anxiety

# Social History: She does not smoke and does not drink alcohol. Family History: Significant for history of chronic hypertension. Current Medications:

Levaquin, Lasix, Protonix, Effexor, Pulmicort. Perforomist, Solu-Medrol, and Klonopin.

# Vitals:

Temperature | 98.6°F
Pulse | 112
Respirations | 16
Blood Pressure | 139/71
SpO2 | 96%

# Physical Examination

# General: The patient is alert, oriented, conversant. appears to be short of breath. HEENT: Eyes show normal conjunctivae and normal sclerae. Normal-appearing ears and nose.

# Neck: Supple. No lymphadenopathy. No masses.

# Chest: Shows significantly diminished air entry with no wheezes and no crackles.

# Heart: Regular. SI and S2 with no murmur and no rub.

# Abdomen: Soft. nontender. No organomegaly. No masses. Extremities: Lower limb shows no edema. No clubbing. No cyanosis. Skin: No skin rash. Normal temperature.

# Neurologic: Normal power. Normal tone. No tremors.

# Psychological: Alert and oriented with good memory.

# Laboratory Data:

Her lab work showed a pH 7.61, pCO2 is 30. pO2 is I 05, bicarb is 30, BUN is 11, creatinine is 0.77. potassium is 4. White cell count 13.2. hemoglobin is 14.3, platelet count 354. Troponin is negative. EKG showed sinus tachycardia with no acute ST changes. Chest x-ray showed chronic degenerative changes with no evidence of pneumonia.

# Assessment and Plan:

1. Acute on chronic respiratory failure suspect to be secondary to acute exacerbation of chronic obstructive pulmonary disease. Failed outpatient treatment. The patient’s arterial blood gas shows evidence of respiratory alkalosis. In the meantime, I am going to check D-dimer to rule out evidence of pulmonary embolism. I am going to start the patient on IV heparin. If the D-dimer comes back elevated, we will proceed with CT angiogram to rule out pulmonary embolism. I am going to consult Pulmonary Service for evaluation. We will continue bronchodilator therapy and IV antibiotic and IV steroids. We will also obtain physical therapy.

2. The patient has respiratory alkalosis. We are going to check for evidence of pulmonary embolism.

3. The patient has chronic anxiety disorder. We will continue home medication.

4. Mild persistent asthma.

1. No further deep vein thrombosis prophylaxis. The patient is on IV heparin.

2. We will obtain physical therapy assessment.

This management plan has been discussed with the patient and the nursing staff.

The patient will be seen and managed by Dr. Jacobs tomorrow morning who is doing the inpatient hospital rounds.

# Electronically Signed By: Marilyn Carol, MD

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