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</span><br/><br/><u><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px">History and Physical Examination</span></span></u><br/><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px">Patient Name: Halonen, Rune<br/>
Date: 10/23/17<br/>
Unit: Emergency Department<br/>
Location: Newton-Wellesley Hospital<br/>
Data Source: Patient, and EMS staff. <br/>
<br/>
<b>Chief Complaint: </b>Dyspnea, syncope.<br/>
<br/>
<b>History of Present Illness: </b>Patient is a 23 year old, single Caucasian male that presents to the emergency department after EMS transport with an acute shortness of breath and episode of syncope that began approximately twenty minutes ago. The patient is lying supine in bed and is awake, alert and oriented x 4. Appears agitated and in a state of hysteria, unable to catch his breath. <br/>
<br/>
<b>Current Medications</b><br/>
None presently<br/>
<br/>
<b>Past Medical History</b><br/>
General: Relatively good <br/>
Infectious Diseases: Usual childhood illnesses. No history of rheumatic fever. <br/>
Immunizations: Flu vaccine yearly. <br/>
Allergic to Sulfa antibiotics- Patient developed hives and anaphylactic reaction at age 13. <br/>
Transfusions: None.<br/>
<br/>
<b>Past Surgical History</b><br/>
1. Normal childbirth 23 years ago.<br/>
2. 2004- ruptured appendix at age 13.<br/>
<br/>
<b>Review of Systems (ROS)</b><br/>
<i>General:</i> Denies weakness, fatigue, fever, chills, night sweats, heat intolerance.<br/>
<i>Eyes: </i>Denies eye pain, acute visual loss, or significant visual changes. <br/>
<i>Ears, Nose, Mouth, Throat: </i>Denies hearing loss, tinnitus, vertigo, ear pain, ear  discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore  throat, or speech difficulty. <br/>
<i>Cardiovascular: </i>Patient denies history of palpitations, angina or edema. <br/>
<i>Respiratory: </i>No prior history of wheezing, hemoptysis, asthma, PNA, TB, or emphysema. <br/>
<i>Gastrointestinal: </i>Negative for nausea/vomiting, hematemesis, melena, dysphagia, anorexia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain. <br/>
<i>Genitourinary: </i> No dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.  <br/>
<i>Musculoskeletal:  </i>Denies backache, joint pain, stiffness.<br/>
<i>Neurologic: </i>Past history of migraine headaches, No prior complaints of dizziness, loss of sensation, loss of function, numbness, tingling, or weakness.<br/>
<i>Hematological:</i> Denies lymphadenopathy, bleeding, bruising, anemia.<br/>
<i>Endocrine:</i> Denies a history of thyroid problems, anemia, or diabetes mellitus.<br/>
<i>Psychiatric:</i> Denies history of anxiety, depression or suicidal ideation.<br/>
</span></span><br/><b><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px">Physical Exam</span></span></b><br/><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px">Athletic, well-nourished white male, appearing slightly pale and diaphoretic. In moderate distress, neatly dressed and groomed.<br/>
<i>Vitals:</i> T- 98.4° F HR- 134; BP 130/78; RR- 40; O2 Sats- 90% on 2L oxygen <br/>
<i>General: </i>No abnormality detected, patient somewhat short of breath but able to speak in full sentences.<br/>
<i>Psychiatric: </i>Patient appears anxious, hysterical.<br/>
</span></span><br/><b><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px">HEENT</span></span></b><br/><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px"><i>Head:</i> Normocephalic. <br/>
<i>Eyes:</i> Visual acuity 20/20 without corrective lenses. Pupils equal, round and reactive to  light, Extraocular movements intact. Conjunctiva pink with no redness or exudate. Eyelids without lesions. Sclera without icterus. Fundi‐ discs sharp.  Vessels without hemorrhages or exudate.  <br/>
<i>Nose:</i> Nares  patent and‐mucus membranes moist without erythema or exudates. No sinus  pain to palpation.  <br/>
<i>Mouth:</i> Good dental hygiene. Lips smooth and moist, slight cyanosis present. Gums,  tongue and mucosa without lesions. Tonsils slightly enlarged but not  erythematous and without exudates. Pharynx clear. Uvula moves up in midline. Normal gag reflex.  Neck: Neck supple without thyromegaly, normal ROM, trachea midline with no deviation, no carotid bruit present. No lymphadenopathy.<br/>
<i>Pulmonary: </i> Airway patent. Chest symmetrical expansion.  No deformities on posterior chest wall. Lungs <br/>
clear to auscultation and percussion, without adventitious sounds. No chest pain. Moderate dyspnea with hyperventilation. Moderate tachypnea present.<br/>
<i>Cardiovascular: </i>No JVD. No deformities on anterior chest wall. PMI at 5 th intercostal space,  midclavicular line. Heart sounds‐RRR, Normal S1 and single S2. No S3, S4, rubs, or murmurs. Carotids 2+ bilaterally without bruits. <br/>
<i>Gastrointestinal: </i>The abdomen is soft, non tender, non-distended. There are normoactive bowel sounds. There is no hepatosplenomegaly and no masses are present. 10 cm diagonal appendectomy scar present on right lower quadrant.<br/>
<i>Rectum:</i> The skin is without erythema or induration. Sphincter tone normal. There are no masses palpated on digital exam. The prostate is firm, non-tender, without nodules.  Stool brown, negative for blood. <br/>
<i>Genitourinary: </i>The testicles are descended bilaterally. They are firm, non tender, and without masses or lesions. No penile lesions are noted and there is no discharge from the urethra. The scrotum is without induration, erythema, or edema. No hernias are palpated in the inguinal canals. <br/>
<i>Musculoskeletal: </i>Full range of motion. no pain, edema, or deformity. Pulses full and equal. No clubbing, or edema. Mild cyanosis of fingernails.<br/>
<i>Neurologic: </i> Awake, alert and fully oriented x 4. Cranial nerves II‐VII intact, Muscle bulk is appropriate in upper and lower extremities. Motor strength is 5/5 in upper and lower extremities bilaterally. Sensation intact to light touch, temperature, and pinprick. DTRs 2+ in biceps,  triceps, quadriceps and ankles. Gait full without impairment. Coordination‐able  to do rapid alternating movements well and finger to nose test well with eyes open and closed.  Babinski responses downgoing bilaterally. Romberg negative.<br/>
<br/>
<b>Labs, EKG</b><br/>
All laboratory data within normal limits. EKG shows normal sinus rhythm with no abnormalities noted.<br/>
<br/>
<b>Social/Family History </b><br/>
Mr. Halonen is a 23-year-old, gay, Caucasian male who is currently working as a interior designer for Nest Interior Design, in Boston.  He is single, has no children, and is not currently involved in a relationship. He owns his own home, located in Newton, Massachusetts. He moved to the area two years ago from Toronto, Canada, after graduating from the University of Toronto, with a Bachelor of Arts degree in Interior Design. His parents Patrik and Kirsti, are married and live in Toronto with three other children still living at home.  Mr. Halonen has two teenage brothers, Elias and Markus and a younger sister, Elisabet. He has limited contact with his family, and Mr. Halonen reports the he has a very strained relationship and poor communication with his parents in regards to his homosexuality.<br/>
<br/>
There is no known family history of hypertension, diabetes, or cancer. Mr. Halonen is a non-smoker, drinks socially, and refrains from the use of recreational drugs. </span></span><br/><br/><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px"><b>Impression </b><br/>
1. Rule out asthma, seizure activity, and cardiac arrhythmias. Admit to unit for further observation overnight.<br/>
<br/>
<b>Plan </b><br/>
1.Discontinue oxygen therapy and observe patient while breathing room air. Maintain patient comfort with sedation as needed. Follow up on serial physical exams, spirometry, EKGs, and labs. <br/>
2. Obtain echocardiogram and stress test.<br/>
3. If echocardiogram and stress test are normal, discharge to home with Holter monitor for 24 hour monitoring.<br/>
4. If necessary,  refer patient to psychotherapist for a mental health evaluation for suspected panic disorder.<br/>
</span></span><br/><div style="text-align: center"><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px">------------------------------------------------------------------</span></span>​</div><span style="font-family: 'Book Antiqua'"><span style="font-size: 18px"><br/>
<i>"Here Rune, let me get that hospital band off your wrist. I'm sure you're plenty tired of looking at it by now." </i>said Shelley, a friend from work that had come to pick him up from the hospital after being discharged. <br/>
<br/>
Rune had just arrived home, and Shelley escorted him inside the old Victorian that Rune had gushed about at work. A pair of scissors was removed from a wooden knife block in the kitchen, used to cut through the plastic identification band, and the yellow band that warned the medical personnel of his allergy to sulfa antibiotics.<br/>
<br/>
<b>"Thanks so much for picking me up, Shel. I didn't know who else I could call at this time of day." </b>Rune replied, smiling as Shelley relieved him of the plastic bracelets and disposed of them. <br/>
<br/>
<i>"It's no trouble, Rune. You know me, I look out for my friends. Maybe you can give me a tour of the place when you're feeling better. It really does look lovely from the outside. Well, anyway.. do you need anything before I go?"</i> she asked, thinking she heard a door close upstairs.<br/>
<br/>
<b>"Um. I think I'm all good. I'm just gonna get some sleep. Couldn't get a whole lot of that with all the monitors beeping and nurses coming in to check on me."</b> Rune explained, tilting his head slightly as he heard the creaking sound upstairs.<br/>
<br/>
<i>"That was weird. Could've sworn I heard a door close. Hm." </i>Shelley murmured. <i>"Okay, you better call me if you need anything. I don't care what time it is, just call me Rune. You hear?"</i><br/>
<br/>
<b>"Old house. Foundations settling. I promise. I'll call if I need anything Shel. Honest. Now go home and spend some time with Bill and the kiddos." </b>he laughed, walking his friend and co-worker to the front door.<br/>
<br/>
The two laughed about how cold it was getting out, and Shelley departed for home. Rune closed the front door, and paused.<br/>
<br/>
He still remembered seeing a man standing there, he did. Then he couldn't breathe, and the moving men caught him before he fell down and passed out. All the tests were normal. He was healthy, and had no explanation other than stress that could've caused his reaction. He gingerly stepped away from the front door after locking the deadbolt, and turned off the hall light. He was still wearing the Holter monitor, the ECG leads attached by cords that wound through and underneath his button down shirt. <br/>
<br/>
Rune ascended the stairs quickly, and when he reached the top of the stairs suddenly had an overwhelming feeling that someone was watching him and it scared him. He bolted for his bedroom door, and slammed it shut. Rune made a beeline for his bed, and thrust the blankets and comforter over his head, afraid of what he might see if he removed the blankets. He lay there in the darkness, until a sense of exhaustion replaced his terror.<br/>
<br/>
Rune fell asleep, and remained sleeping soundly until dawn broke over the horizon.<br/>
</span></span><br/><span style="font-size: 22px"><br/>
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