HPI: Patient is a 46 year old male who complains of constant and severe shortness of breath which started four hours ago after patient got home from the airport after a business trip.
PFSH: No allergies. Smokes about 1 PPD times 20 years. No family history of premature cardiovascular disease of primary lung disease.
ROS: Cardiovascular: Negative for palpitations or chest pain. Pulmonary: negative for hemoptysis or cough. GI: negative for N/V. All other systems reviewed and are negative.
PHYSICAL EXAM: Well-nourished male in some distress. Vitals: 160/80, 115, 28. EYES: PERRL with normal conjunctivae and lids. ENMT: Normal nasal mucosa and oropharynx. NECK: Trachea midline. No thyromegaly. LUNGS: CTA with somewhat increased respiratory effort. CARDIOVASCULAR: RRR, no MRGs. No peripheral edema. ABDOMEN: Soft and non-tender.. No HSM. MUSCULOSKELETAL: Normal gait and station. Homan’s sign is negative. No digital clubbing. PSYCH: A & O X 3 with appropriate affect.
CBC and chemistry panel is WNL. EKG was reviewed and shows sinus tachycardia, RAD and a flipped T wave in lead III. CXR was reviewed and shows no infiltrate or pulmonary vascular congestion.
