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PATIENT PRESENTATION

Chief Complaint

“I am having trouble breathing.”

History of Present Illness

RM is a 64-year-old male who comes to the emergency department with fever, shortness of breath, and cough. He complains of a productive cough with discolored sputum for the past week. Over the past few days, he complains of fever, chills, and pressure on his chest when he coughs. He has been hospitalized two times in the past year approximately 6 months ago for COPD exacerbation.

Past Medical History

Chronic obstructive pulmonary disease (COPD)

Diabetes type II

Hypertension (HTN)

Surgical History

N/A

Family History

Father: had COPD and HTN and passed away from a stroke

Mother: is 88 y/o, alive, with coronary artery disease

Social History

He lives alone, never married.

He smokes 1 pack per day for 30 years. He quit 5 years ago.

He drinks beer occasionally, 1 to 2 times per month.

Immunization

Up to date

Insurance

United Healthcare

Allergies

No known drug allergies

Home Medications

  • Anoro Ellipta 62.5 mcg/25 mcg: 1 puff daily

  • Albuterol metered-dose inhaler: 2 puffs every 4 hours as needed for shortness of breath

  • Lisinopril 10 mg PO daily

  • Metformin 1000 mg PO twice daily

Physical Examination

Vital Signs

Temp 101.5°F, P 128, RR 24, BP 118/78 mmHg, SpO2 70%, Ht: 5′6″, Wt: 72.7 kg

General

Chronically ill-appearing male with shortness of breath in moderate distress.

HEENT

Normocephalic, atraumatic, PERRLA, EOMI.

Pulmonary

Diminished breath sounds and crackles bilaterally.

Cardiovascular

NSR, no m/r/g.

Abdomen

Soft, non-distended, nontender.

Genitourinary

Normal male genitalia, no complaints of dysuria, or hematuria.

Neurologic

Awake, alert.

Extremities

No edema.

Laboratory Findings

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Na 137 mEq/L

RBC 3.8 × 106/mm3

WBC 23.1 × 103/mm3

Procalcitonin 1.9 ng/mL

K 4.1 mEq/L

Hgb 12.1 g/dL

Neutrophils 67%

Lactic acid 2.3 mmol/L

Cl 103 mEq/L

Hct 35%

Bands 15%

CO2 27 mEq/L

MCV 91 ...

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