MDM //

Patient presenting with shortness of breath. Given exam and history, suspect likely COPD exacerbation. These constellation of symptoms are similar to prior flares without overt deviations from normal exacerbations. Given clinical findings and history, low suspicion for pneumonia, pneumothorax, or acute valvular failure. No swelling of lower extremities, crackles on exam, lower suspicion for CHF, pulmonary edema. Patient with minimal risk factors for pulmonary embolism and atypical ACS. As such, will trial bronchodilators, steroids, monitor respiratory status closely, reassess. Patient much improved after breathing treatment. Satting well on room air, ambulating without difficulty. No drop in stats with ambulation. Will refill albuterol if desired, discharge with short course of prednisone. XXX Labs unremarkable, BNP within normal limits and troponin negative. Low suspicion for cardiac etiology of symptoms. XXX Patient prescribed antibiotics due to abnormal x-ray, increased sputum production.



[Back to Main Menu]