Shortness of Breath SOB Case Study
Shortness of Breath SOB Case Study
HPI: Patient went to the hospital on 9/15/20 and presented with acute respiratory failure. Patient was admitted with sepsis/bacterial pneumonia. While he was in the hospital he was treated for pneumonia with an antibiotic, and acute CHF and was diuresised with lasix. Patient had new onset atrial fibrillation and was placed on a beta blocker, asa, and Xarelto. During the hospitalization he developed apistaxis and pupura. The Xarelto and ASA was stopped.
Past Medical History: Polyosteoarthritis, type two DM, C KD, HTN, HLD, peripheral neuropathy with history of left foot drop, hyperkalemia, hyperparathyroidism, vitamin D deficiency, gout, hemachromatosis.
Past Surgical History: bilateral carpal tunnel syndrome with surgery.
Social History: married, denies ETOH, recreational drug use, and tobacco.
Medications (Medication list from home): Metoprolol Tartrate 100 mg po bid, Basiglar 15 units sq, Vitamin D 2000 IU, Gabapentin 300 mg po TID, Metformin 1000 mg po bid.
Labs (Most recent results): wbc 12.7 h/h 10.0/30.0 pl 87 gl 322, bun 62 cr 4.45, na 137 k 4.9
Imaging CXR: CHF
Allergies: No known allergies.
Code status: Full code
Review of Systems:
HEENT – No sore throat. No headache. No nasal congestion. No earache. No eye pain.
Neurological – Numbness and tingling in his bilateral upper extremities. Jerky uncontrolled movements with his hands.
Cardiovascular – No chest pain, no palpitations. Some swelling in his lower extremities.
Respiratory – SOB, productive cough.
Gastrointestinal – No N/V/D, no abdominal pain
Musculoskeletal – Foot drop left foot.
Temp: 101.2 BP: 92/68 Pulse: 99 RR: 22 Blood sugar: 210 mmol/L O2 Saturation: 89%. Pain level: 3
Physical Exam:
GENERAL: awake, alert and oriented with confusion.
HEENT: normocephalic, anicteric sclerae, pink palpebral conjunctivae.
Neuro: PERRLA
Respiratory: Crackles, breath sounds diminished at the Bases, wheezing, no rales.
Heart: positive S1S2, irregular rhythm, no M/R/G, 2+ edema.
Abdomen: flat, + bowel sounds, soft, nontender
Mental status: calm, co-operative
Skin: dry, intact, no rashes, no itching
Musculoskeletal: , no tenderness, moves all his extremities. Left drop foot jerky movements with hands.
QUESTIONS:
- (Inpatient setting) What would your assessment of this patient be? Please provide a comprehensive assessment of chronic and acute diagnosis.
- (Inpatient setting) What would be your treatment plan for this patient? Please provide a comprehensive treatment plan of chronic and acute diagnosis.
- (Outpatient setting) The patient improves and is discharged from the hospital. As the primary care provider, during the subsequent follow-up what would you do for this patient during this office visit?
