H&P 1

Identifying data 

Name: MH 

Sex: Female

Age: 39

Date and time: 3/11/2021 8:00 AM 

Location: New York Presbyterian Queens Hospital, Emergency Department

Source: self, reliable

Interpreter: Spanish 

Chief complaint: “cough and shortness of breath” X1.5 weeks

History of present illness: 

MH is a 39-year-old female with significant past medical history of breast cancer and recent Covid infection presenting to the ED with shortness of breath and cough for one and a half weeks. She tested positive for Covid on January 15, 2021 and her symptoms had since resolved. On February 4, 2021 she presented to primary care with cough and was diagnosed with pneumonia and bronchitis. She was treated with antibiotics and her symptoms improved. A week and a half ago she began coughing and experiencing shortness of breath. Five days ago she stated her cough started becoming more severe. The cough is associated with dull chest pain that worsens with inspiration. The cough is productive of “thick saliva”. She admits to palpitations, general weakness, shortness of breath, and chest tightness. She denies fever, chills, nausea, vomiting, wheezing, hemoptysis, rhinorrhea, sneezing, stuffy nose, sore throat, headache, lightheadedness, diarrhea, abdominal pain. She states she came to the ED today because her cough was so severe it prevented her from sleeping last night. 

Past medical history:

Breast cancer of the left breast in 2019, treated with lumpectomy, radiation, and tamoxifen. 

Covid + January 15, 2021

Pneumonia and Bronchitis February 4, 2021, treated with antibiotics, patient unable to recall which antibiotics were used. 

Hospitalizations:

Hospitalized for surgery (see below) and radiation treatment last treatment September 2020. 

Immunizations:

Up to date 

Past surgical history: 

Left lumpectomy due to breast cancer in 2019, at Elmhurst hospital. Denies complications

Medications:

Tamoxifen 2mg twice a day for breast cancer. Denies other daily medications 

Allergies:

No known allergies to medications, food or environment

Family history:

Mother: diabetes 

Father: hypertension

Three children: Alive and well

Denies family history of lung disease, cancer, kidney disease, thyroid disorders, other cardiac or metabolic disorders. 

Social history: 

Patient lives at home with her husband and three children. Patient denies smoking, drinking alcohol or use of illicit drugs. Patient is sexually active with her husband only. 

Review of systems: 

General: admits to general weakness. Denies fever, chills, nausea, vomiting. 

Head: denies trauma, loss of consciousness, headaches, confusion, lightheadedness

Neurologic: denies syncope, decreased sensation, numbness, tingling

Eyes: denies blurred vision and discharge

ENT: denies rhinorrhea, stuffiness, sneezing, sore throat, neck pain 

Cardiac: admits to inspirational chest pain and chest pain with coughing, admits to palpitations. Denies leg edema. 

Pulmonary: admits to cough, shortness of breath, pain with inspiration and sputum production described as clear thick saliva. Denies wheezing, hemoptysis. 

Hematology: denies bruising

Skin: denies itching and rashes

GI: denies diarrhea, constipation, abdominal pain and changes in bowel habits

GU: G3P3, last menstrual period January 15, 2021, was regular. Denies urgency, dysuria. 

MSK: denies joint pain and swelling

Psychiatric: denies anxiety, stress, depression 

Physical exam: 

Vital signs: 

HR: 97 BPM, regular

BP: 143/98, right arm seated

RR: 22 unlabored

T: 36.8 C (98.2 F), oral

Pulse ox: 90% on room air 

Height and weight were not obtained for this patient 

General: 39-year-old female alert and oriented X3, well groomed with good hygiene, appears stated age, not in acute distress, actively coughing with speech. 

Head: no deformities, no trauma

Eyes: pupils equal, round, reactive to light. No icterus or conjunctival injection 

ENT: moist mucous membranes, no erythema, exudate, lymphadenopathy 

Cardiac: regular rate and rhythm, normal S1 and S2. no murmurs, rubs or gallops. Normal distal pulses, no JVD, normal capillary refill, no pitting edema or unilateral calf swelling

Pulmonary: + cough with inspiration on exam. Decreased breath sounds bilaterally. No wheezing, rales, or rhonchi. 

Abdominal: abdomen soft and nontender

Skin: no cyanosis, rashes, bruises 

Differential diagnosis: 

1. Pneumonia 
2. Pulmonary embolism 
3. Covid-19
4. Myocarditis
5. Bronchitis 
6. Influenza 

Labs and imaging: 

1. CXR: shows extensive bilateral interstitial pneumonia
2. EKG: normal sinus rhythm at 71 beats per minute
3. Covid nasopharyngeal swab: negative
4. Influenza A and B nasopharyngeal swab: negative 
5. CBC with differential: within normal limits
6. BMP: within normal limits
7. Urine hcg: negative
8. aPTT: within normal limits
9. CRP: within normal limits
10. Creatine kinase: within normal limits
11. D-dimer: <150 (within normal limits)
12. Ferritin: within normal limits
13. LDH: within normal limits
14. LFT: within normal limits
15. PT/INR: within normal limits
16. Reticulocyte count: within normal limits
17. Troponin: within normal limits
18. Fibrinogen: within normal limits
19. Procalcitonin: within normal limits

Assessment: MH is a 39-year-old female with past medical history of breast cancer and recent covid-19 infection presenting to the ED with cough and shortness of breath for one and a half weeks. The cough is productive of clear phlegm, and associated with chest pain. The chest pain is dull and present only with cough and inspiration. The patient is afebrile. Physical exam reveals hypoxia on room air, decreased breath sounds bilaterally, and cough with inspiration. Chest X-ray reveals extensive bilateral interstitial pneumonia. Laboratory examination are all within normal limits. Imaging and clinical presentation consistent with bilateral interstitial pneumonia.

Plan: 

1. Place patient on 4L nasal cannula and reassess O2 saturation:
   1. Patient 97% O2 on 4L nasal cannula 
2. 1L bolus of normal saline 
3. Acetaminophen 650 mg orally, once 
4. Treat with Azithromycin IV 500mg D5W 250 mL over 60 minutes, once
5. Treat with ceftriaxone IV 1000 mg D5W 50 mL over 30 minutes, once
6. Obtain blood cultures 
7. Admit patient to regular medical floor for observation and treatment of bilateral interstitial pneumonia and hypoxia on room air 

H&P 2

Identifying data:

Name: AU

Sex: Female

Age: 18 

Date and time: 3/8/21, 15:00 

Location: New York Presbyterian, Queens Hospital, Emergency Department

Source of information: self, reliable 

Chief complaint: dizziness X 5 hours

History of present illness: 

AU is a 18-year-old female with past medical history of iron deficiency anemia requiring blood transfusions presenting to the ED with a complaint of dizziness for the past five hours. This morning the patient awoke feeling dizzy, complaining of vomiting, weakness and abdominal pain. She describes the pain as  7/10 crampy located across both lower abdominal quadrants. The patient says she felt like she was going to faint. She admits to numbness of arms and legs, and slight shortness of breath this morning which has since resolved. Patient states she has been having her “period” every day since early November 2020, although she is unsure of the exact start date. She has been having weeks of heavy bleeding alternating with light bleeding since that time. The past few weeks she has been bleeding heavily, she states she has been stacking 2-3 pads at a time and soaking through them three-four times a day. She endorses the passage of blood clots. The patient has experienced this bleeding before and was treated with oral contraceptive pills, but she has stopped taking those pills a year ago. Prior to the arrival to the ED the patient took 2 tylenol which did not help. She has not seen her OB/GYN for over a year but has an appointment scheduled with them in two days. She admits to fatigue, dizziness, nausea, vomiting, numbness, tingling, shortness of breath, and abdominal pain. Patient denies sexual activity,  fever, cough, sick contacts, loss of consciousness, headache, blurred vision, swollen lymph nodes, chest pain, palpitations, cough, pain with inspiration, hemoptysis, bruising, petechiae, diarrhea, constipation, oral or rectal bleeding, and changes in bowel habits. She came to the ED today because she felt “awful” and did not want to wait until her appointment in two days to be seen.

Past medical history: 

Present illnesses: iron deficiency anemia and abnormal uterine bleeding treated with blood transfusion in 2017, at which point she was started on oral contraceptive pills. She does not know the name, and has since stopped taking them a year ago. 

Past illnesses: unknown cardiac valvular disease 

Immunizations: information was not obtained for this patient 

Past surgical history: patient admits to cardiac surgery for her valvular disease, does not know what kind of surgery, where and when it was done. 

Medications: patient denies taking daily medications including oral contraceptive pills. 

Allergies: patient denies allergies to medications, food and environment

Family history: patient’s sisters both have thyroid disorders but patient is not sure what type. Parents alive and well. Patient denies family history of cardiac disease, kidney disease, lung disease, cancer, and diabetes. 

Social history: patient lives at home with her parents and siblings and attends online school. Patient denies smoking, vaping, alcohol use, or illicit drug use. Patient states she has never been sexually active.  

Review of systems: 

General: patient admits to nausea, vomiting, fatigue. Patient denies general weakness, fever, chills, diaphoresis.

Head: patient denies loss of consciousness, headache, confusion 

Neurologic: patient admits to numbness and tingling of extremities (see HPI). Patient denies syncope. 

Eyes: patient denies blurred vision 

ENT: patient denies swollen lymph nodes

Cardiac: patient denies chest pain and palpitations.

Pulmonary: patient admits to shortness of breath. Patient denies cough, pain with inspiration, hemoptysis, and history of asthma

Hematology: patient admits to history of anemia, patient denies bruising and petechiae. 

GI; patient admits to abdominal pain (see HPI). patient denies diarrhea, bleeding, dysphagia, constipation, changes in bowel habits 

GU: Patients LMP began in November 2020 and never stopped. Patient admits to abnormal vaginal bleeding.  the patient denies urgency, dysuria, polyuria. 

MSK: patient denies joint pain and swelling 

Breast: patient denies skin changes, discharge, pain or masses of the breast. 

Physical exam:
Vital signs:

  HR 88 BPM regular

 BP 112/71

RR 16 unlabored

 T 36.9 C (98.4F), orally

 Pulse ox 97.7% on room air.

 Height, 167 cm, weight: 65 kg, BMI: 23.3 

General: 18-year old female, alert and oriented X3 to person, place and time. Appears stated age, with normal hygiene, not in acute distress but appears tired. 

Head: normocephalic, atraumatic

Eyes:  + pale conjunctiva, pupils equal, round, reactive to light,  no icterus or conjunctival injection. 

ENT: mucous membranes moist, no erythema or exudate on the pharynx, no lymphadenopathy. Trachea midline. Thyroid is not enlarged. 

Cardiac: regular rate and rhythm, with normal S1 and S2. no murmurs, rubs or gallops. Normal distal pulses, capillary refill <2 seconds bilaterally. 

Pulmonary: lungs are clear to auscultation bilaterally, no wheezes, rales or rhonchi. 

Abdominal: bowel sounds present in all four quadrants, abdomen is soft and non tender, with no distention, fluid or hepatosplenomegaly. 

GU: +blood in the vaginal vault. No lymphadenopathy or lesions. 

Skin: + pallor, no bruises, rashes or petechiae. 

Differential diagnosis: 

1. Iron deficiency anemia
2. Ectopic pregnancy 
3. Hypovolemia 
4. Uterine leiomyoma 
5. Endometrial polyp 
6. PCOS 
7. Orthostatic hypotension 
8. Ovarian torsion

Labs and imaging and other orders: 

1. Orthostatics: negative 
2. CBC with differential: WBC 9.63, Hgb 9.5, HCT 32.7, platelets 271,000. MCV, MCH, MCHC low. 
3. Blood cell morphology: anisocytosis, poikilocytosis, polychromasia.  
4. Urine hcg with reflex quantitative hcg: negative 
5. EKG: shows normal sinus rhythm 
6. Type and screen: B+ 
7. Pelvic and abdominal US: 1.7cm cyst in the right ovary. No abnormal findings of the uterus. No ovarian torsion. 
8. BMP: within normal limits
9. LFTs: within normal limits
10. Urinalysis: within normal limits
11. Coagulation studies: low aPTT, elevated PT/INR 

Assessment: AU is a 18-year-old female with past medical history of iron deficiency anemia requiring transfusions, presenting to the ED with dizziness, abdominal cramping, vomiting and weakness for five hours. Patient has been experiencing vaginal bleeding since November 2020. Physical exam and labs are consistent with iron deficiency anemia. Abdominal and pelvic US shows a  right ovarian cyst. 

Plan: 

1. Normal saline bolus 1000 mL in the ED
2. Cardiac monitor in the ED
3. Discharge home with:
   1.  Ascorbic acid 100 mg tablets with instructions to take two once a day. 
   2. Ferrous sulfate 325 mg tablets with instructions to take one tablet once a day.
4. Advised to keep appointment with OB GYN in two days for further workup of abnormal bleeding and ovarian cyst

H&P 3

Identifying data: 

Name: AL 

Sex: Female

Age: 44

Date and time: 3/22/21 7:30AM

Location: New York Presbyterian Queens Hospital, Emergency department 

Source of information: self, reliable 

Chief complaint: palpitations X this morning 

History of present illness: 

AL is a 44-year-old female with no past medical history presented to the ED with a complaint of palpitations since this morning. She stated that the palpitations woke her up this morning and have not resolved. She admitted to chest pain that is located over her left chest, non radiating, non exertional, non pleuritic. She described it as dull, 3/10 and its onset simultaneous with the palpitations. She admitted to a similar event in the past that resolved within five minutes and she never sought treatment. She denied the use of medications, recreational drugs, and caffeine. She denied diaphoresis, syncope, shortness of breath, lightheadedness, dizziness, nausea, vomiting, diarrhea, weakness, fatigue enlarged thyroid, blurry vision, pallor, unilateral leg swelling, hemoptysis, fever, chills, sick contacts, recent travel. She came to the ED today because the palpitations did not resolve as they did in the past.

Past medical history: 

Patient denied past medical history 

Hospitalizations: 

Patient denied hospitalizations 

Immunizations: 

Patient stated she is up to date on vaccinations including annual influenza vaccination 

Past surgical history: 

Patient denied past surgical history 

Medications: 

Patient denied taking daily medications 

Allergies: 

Patient denied allergies to medication, food and environment 

Family history: 

Denied family history of cardiac disease, thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract diseases, psychiatric disorders, nervous disorders, metabolic disorders, endocrine disorders.

Social history: 

Patient lives with husband and two children. Patient denied use of tobacco, alcohol and recreational drugs. 

Review of systems:

General: denied fever, chills, nausea, vomiting, fatigue, general weakness, diaphoresis, night sweats and changes in weight

Head: denied trauma, loss of consciousness, headache, confusion, lightheadedness, changes in vision 

Neurologic: denied syncope, slurred speech, neck stiffness, decreased sensation, numbness, tingling 

Eyes: denied blurred vision, discharge. Does not wear corrective lenses

ENT: denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain

Cardiac: patient denied leg edema, claudication, known heart murmurs

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis 

Hematology: patient denied bruising, anemia 

Skin: patient denied rash, sores, itching 

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence, patient is G2P2 LMP 3/5/21. 

MSK: patient denied joint pain and swelling 

Breast: patient denied skin changes, masses, lumps, pain, discharge. 

Psychiatric: patient denied anxiety, depression, mood changes. 

Physical exam: 

Vital signs:

HR: 174, regular

BP: 114/68 right arm, seated

RR: 15, unlabored

Temperature: 37 C, orally 

O2: 98% on room air

Height: 165 cm, weight: 58.9 kg, BMI: 21.6

General: 44-year-old female, alert and oriented X3, well groomed with good hygiene, appears stated age and is not in acute distress. 

Head: normocephalic and atraumatic

Eyes: pupils equal round and reactive to light, non icteric no conjunctival injection 

ENT: mucus membranes moist, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. 

Cardiac: +tachycardia to 170s, regular rhythm, S1 and S2 auscultated. no murmurs, rubs or gallops. Radial pulses 2+ bilaterally, capillary refill < 2 seconds bilaterally. No leg edema. 

Pulmonary: lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi, tachypnea. Normal respiratory effort no retractions. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. 

Skin: no rashes, bruises or scars. No pallor noted. 

Extremity: full range of motion, strength grossly intact in upper and lower extremity. No unilateral calf swelling or tenderness. 

Differential diagnosis: 

1. Arrhythmia
2. MI 
3. Hyperthyroidism 
4.  Pulmonary embolism 
5. Anemia 

Labs and imaging: 

1. EKG: SVT at a rate of 174.
2. CXR: within normal limits 
3. LFT: within normal limits
4. BMP: within normal limits
5. Magnesium and phosphorus: within normal limits
6. Pro-BNP: within normal limits
7. GFR: within normal limits
8. CBC: within normal limits
9. Troponin: negative 
10. Thyroid function (TSH, T4): within normal limits
11. D-dimer: negative
12. Hcg: negative

Assessment: 

AL is a 44-year-old female with no past medical history who presented to the ED with a complaint of palpitations and chest pain that awoke her this morning. The chest pain was described as dull, non-exertional, non radiating and non pleuritic. Cardiac exam revealed tachycardia. EKG revealed SVT. Labs and imaging were within normal limits. Patient’s presentation was consistent with SVT. 

Plan:

1. Place patient on cardiac monitor: showed SVT at a rate between 170-200 
2. Place IV 
3. Attempt vagal maneuvers: patient converted to NSR at a rate of 79 with blowing into a syringe.
4. Troponin: second troponin was negative
5. Patient educated about blowing into a straw or syringe if this happens again.
6. Patient discharged with cardiology referral.