CASE 2 - Clinical Summary

• 82 year old white female came to the hospital with a chief complaint of shortness of breath.
• Past Medical History - coronary artery disease, atrial fibrillation, asthma.
• Present Illness - Four day history of yellow sputum, decreased appetite, chills, nausea; No chest pain, no leg edema.
• Review of systems - otherwise unremarkable.
  
• Social History - Heavy smoker - 4 packs per day x 25 years.

Physical Exam

• General appearance - alert, oriented elderly female with labored breathing.
• Vital signs - temperature 102, Heart rate - 92, RR 26, O2 saturation - 93%, BP - 96/60.
  
• HEENT - no evidence of inflammation, no masses, trachea is midline, thyroid not enlarged.
  
• Chest- symmetrical, slightly labored breathing.
  
• Heart - regular rhythm, no murmurs, rubs or gallups.
  
• Abdomen - soft, no tenderness, masses or hepatosplenomegaly, normal bowel sounds.
  
• Extremities - no clubbing, cyanosis or edema.