LK is a 67yo female       Ht 5’6”     Wt 79.6kg         BSA: 1.89 m²

CC: Difficulty Breathing

HPI: 67 yo female brought to ED on 08/23/2011 for SOB present over past day or two with minimal discomfort on deep breathing. Denies any leg pain, no fever, no cough, no upper resp. system symptoms.

PMH: Malignant melanoma on back 6 years ago that has currently metastasized to brain and abdomen. History of seizure disorder due to brain metastases. Hypertension, Hyperlipidemia. Has had cholecystectomy & hysterectomy.

FH: None available at this time

SH: Nonsmoker. No alcohol. Is married and has strong support system

Allergies: none

Objective:

Vitals:

08/23/11 07:54

Physical Exam:

Appearance: Awake, alert, in moderate distress

HEENT: Conjunctivae normal, oral mucous membranes are moist, neck is supple, no significant jugular venous distension, lungs are fairly clear to auscultation, no odynophagia or dysphagia.

CV: sinus tachycardia on EKG. Peripheral pulses are intact. Heart is regular rhythm. Denies any symptoms consistent with acute coronary syndrome. No hemoptysis or bleeding.

Ex/Skin: no calf tenderness, no swelling, no rash

Neuro: denies pain, no focal motor changes. No vision or hearing changes.

Abd: soft, nontender, no diarrhea, no constipation, no incontinence, no nocturia

Medications taken at home:

Home Medications:

WHERE DO WE GO FROM HERE?

WHAT INITIAL MEDICATIONS SHOULD BE GIVEN FOR HER SHORTNESS OF BREATH?

WHAT LABS OR TESTS SHOULD WE ORDER?

WHAT DIFFERENTIAL DIAGNOSES SHOULD WE BE CONSIDERING?

I LOOK FORWARD TO YOUR RESPONSES!  ~JIM