Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago. Other known history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking, and has to stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been us
ing her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component Value CBC Component Value
Glucose, Serum 86 mg/dL White blood cell count 5.0 x 10E3/uL
BUN 17 mg/dL RBC 4.71 x10E6/uL
Creatinine, Serum 0.63 mg/dL Hemoglobin 10.9 g/dL
EGFR 120 mL/min Hematocrit 36.4%
Sodium, Serum 141 mmol/L Mean Corpuscular Volume 79 fL
Potassium, Serum 4.0 mmol/L Mean Corpus HgB 28.9 pg
Chloride, Serum 100 mmol/L Mean Corpus HgB Conc 32.5 g/dL
Carbon Dioxide 26 mmol/L RBC Distribution Width 12.3%
Calcium 8.7 mg/dL Platelet Count 178 x 10E3/uL
Protein, Total, Serum 6.0 g/dL
Albumin 4.8 g/dL
Globulin 2.4 g/dL
Bilirubin 1.0 mg/dL
AST 17 IU/L
ALT 15 IU/L