ED Notes

Chief Complaint:

Shortness of breath for 2 days

History of Present Illness:

Patient reports sudden onset of shortness of breath that started 2 days ago. No chest pain, no palpitations, no cough or hemoptysis. Denies recent sick contacts or travel. No prior episodes. No history of similar symptoms. No recent ED visits or hospital admissions. No previous investigations or treatments.

Review of Systems:

• Respiratory: Shortness of breath; denies cough, hemoptysis
• Cardiovascular: Denies chest pain, palpitations

Physical Examination:

• General appearance: Patient appears mildly distressed, speaking in full sentences
• Vital signs: Temp 36.8 °C, BP 132/76 mmHg, HR 94 bpm, RR 18, O2 sat 97 % on room air
• Respiratory: Clear breath sounds bilaterally, no wheeze or crackles

Investigations:

• Chest X-ray: No acute infiltrate or consolidation
• ECG: Normal sinus rhythm; no acute changes
• CBC: WBC 7.5 × 10^9/L, Hgb 139 g/L, Plt 229 × 10^9/L

Assessment & Plan:

• Impression: Sudden onset SOB, no evidence of infection or cardiac event
• Plan: Observation in ED, continue monitoring vitals; oxygen as needed; no immediate treatments started; reassess if symptoms worsen

Final/Working Diagnosis:

• Working diagnosis: Unexplained shortness of breath, likely non-cardiac and non-infectious etiology