Case Date: Jan 04, 2017
Case Title: "Good thing I listen to NPR"
Patient Name: McDaniels, Darryl
Case Authors: Amanda Corbett and Kathryn Fuller
Case: 4007356
Ethnicity: African American
Insurance: VA
Allergies: Amoxicillin (rash)
Age: 68
Sex: M

ED Note

Date/Time: Oct 27, 2016 10:00:00
CC: "I have felt like I have a fever for 2 days, I am coughing alot, and also feel short of breath and dizzy"
HPI: Darryl McDaniels 65-year-old male with a 5 day history of worsening shortness of breath, subjective fevers, chills, right-sided chest pain, nasal congestion, and a productive cough. The patient states that his initial symptom of shortness of breath began approximately 2 days ago and he took some old antibiotics he had in his medicine cabinet. He does not recall what he was but thinks it was a pink tablet. He has been taking an over-the-counter combination cough/cold product and acetaminophen during waking hours for about a week. Despite his slight improvement in symptoms he is still feeling poorly. In addition, he feels dizzy and nauseous most of the day and not sure if that is his illness or secondary to any medications. On presentation to the ED, he is febrile and appears visibly short of breath.
PMH: None
Allergies (Not documented): Amoxicillin (rash - as a child)
Family History:
  Mother: Hypertension, Asthma, Breast Cancer (in remission)
  Father: Hypertension, Stage IV heart failure
Social History:
  Lives in and With: Lives alone, wife passed away
  Occupation: Retired army
  Marital Status and Children: Widowed 2 adult children
  Tobacco (pack years): Past smoker - 25 pack year history (quit in 2007)
  ETOH: 1-2 glasses of red wine per week
  Diet: Standard American Diet
  Exercise: None
  Recreational Drug Use: None
  Complementary Medicine: Fish Oil (sometimes when he thinks about it)

Surgical History: Appendix removed in 2002

ROS: Patient is a good historian. He has been experiencing shortness of breath, a productive cough, nasal congestion, subjective fevers, chills, and pleuritic chest pain that is "right in the middle of my chest." He denies any vomiting, constipation, or problems urinating.

PE:
  Gen: Patient is a well-developed, well-nourished, African-American man in moderate respiratory distress appearing somewhat anxious and uncomfortable.
  Skin: Warm to the touch; poor skin turgor
  HEENT: PERRLA; EOMI; dry mucous membranes
  Neck/Lymph Nodes: No JVD; full range of motion; no neck stiffness; no masses or thyromegaly; no cervical lymphadenopathy
  Lungs/Thorax: Tachypneic, labored breathing; coarse rhonchi throughout right lung fields; decreased breath sounds in right middle and right lower lung fields
  CV: Audible S1 and S2; tachycardic with regular rate and rhythm
  Abd: NTND; (+) bowel sounds
  Genit/Rect: Deferred
  Extremities: No CCE; 5/5 grip strength; 2+ pulses bilaterally
  Neuro: A & O x 3; CN IIxXII intact

Vital Signs:
  Ht: 5
  Wt: 80 kg
  BP: 120/83 mmHg (previous BP: 9/15/2016 = 125/82; 8/1/2016 = 119/83)
  HR: 70
  RR: 25
  Temp: 39.5 C
  O2 Saturation: 94% on room air

Diagnostic Tests (NOT labs):
Impressions:

Hospital Admission Note

Progress Notes

Discharge Note

Clinic Note

Telephone Note

Immunizations

Date: Sep 10, 2010
Immunization Received: TdP

Date: Oct 01, 2012
Immunization Received: Influenza-live attenuated

Date: Feb 02, 1953
Immunization Received: IPV

Date: Apr 05, 1953
Immunization Received: iPV

Date: Jun 15, 1953
Immunization Received: IPV

Date: Dec 04, 1956
Immunization Received: IPV

Diagnostic Tests

Date: Oct 27, 2016
Time: N/A
Test: CXR
Result: RLL infiltrate consistent with pneumonia

Date: Oct 27, 2016
Time: N/A
Test: ECHO
Result: LVH, reduced global left ventricular systolic function, estimated EF 35%; evidence of impaired ventricular relaxation

Date: Nov 25, 2016
Time: N/A
Test: CXR
Result: Resolving RML or RLL infiltrate; opacities throughout, tiny pleural effusions bilaterally; mild cardiomegaly.

Active Medications

Inactive Medications

Active Medications

Start Date	Name	Dose	Frequency	Dosage Form	Route of Administration	Notes
Oct 01, 2011	Hydrochlorothiazide	25 mg	once daily	25 mg tablet	oral	takes all doses
Aug 05, 2011	Lisinopril	10 mg	once daily	10 mg tablet	oral	takes all doses
Sep 15, 2006	Metformin	1000 mg	twice daily	1000 mg tablet	oral	takes all doses
Feb 17, 2014	Salmeterol	1 inh (50mcg)	twice daily	50 mcg/actuation	oral	takes all doses
Feb 17, 2014	Albuterol	2 puffs (180mcg)	as needed for wheezing or SOB	90 mcg MDI	oral	only uses about once every two weeks during the very cold months
Oct 20, 2016	Pseudoephedrine	120 mg	twice daily	120mg ER tablet	oral	been taking around the clock
Oct 20, 2016	Delsym DM (cough plus congestion)	20 mL	every 4 hours	patient is not sure	oral	been taking around the clock; unclear of the product, need to look it up
Oct 20, 2016	Acetaminophen	500 mg	every 8 hours	500 mg capsules	oral	been taking around the clock

Inactive Medications

Start Date	Stop Date	Name	Dose	Frequency	Dosage Form	Route of Administration	Notes
Oct 20, 2016	Oct 22, 2016	Levofloxacin	750 mg	once daily	750 mg tablet	oral	took 3 doses prior to severe foot pain
Oct 27, 2016		ANTIBIOTIC

Labs

Date	0000-00-00 00:00:00
Time	0000-00-00 00:00:00
Sodium (mEq/L)	34
Potassium (mEq/L)
Chloride (mEq/L)
CO2 (mEq/L)
BUN (mg/dL)
Creatinine (mg/dL)
Glucose (mg/dL)
Magnesium (mg/dL)
Calcium, Total (mmol/L)
Caclium, Ionized (mg/dL)
Phosphorus (mg/dL)
Uric Acid (mg/dL)
Osmolality (mOsm/kg)
Anion Gap (mEq/L)
Albumin (g/dL)
Protein (g/dL)
Lactate (mEq/L)
caseid