Evans. Week2. Soap - Patient Information B J 70 y/o Female...

Patient Information:
B. J., 70 y/o, Female, Black
S.
CC: “ Shortness of breath.”
HPI : Onset:Unknown
Location: Respiratory system (lungs)
Duration: Unknown
Characteristics: Shortness of breath with activity
Aggravating Factors: Activities
Relieving Factors: Rest
Treatment: None reported
Severity: Shortness of breath wakes her up at night
Current Medications :
Coreg 6.25 mg PO BID (used for htn, unknown length of time)
Colace 100 mg PO BID (used for stool softner, unknown length of time)
K-dur 20 mEq PO QD (used for potassium supplement, unknown length of time and to replace
depleted potassium from Lasix)
Furosemide 40 mg PO QD (used for diuretic, unknown length of time and to decrease leg
edema)
Allergies: Amoxicillin
PMHx : Hypertension, MI in 2010, 2010-Left Anterior Descending (LAD) cardiac stent
placement. Up to date on flu shot.
Soc Hx: She graduated from high school, and thought about college, but got married right away
and then had kids a short time later. Her son lives in another state. She drinks one 4-ounce glass
of red wine daily. She is a former smoker that stopped 20 years ago.
Fam Hx : Both parents are deceased. Father died of a heart attack; mother died of natural causes.
She had one brother who died of a heart attack 20 years ago at the age of 52.
ROS :
CARDIOVASCULAR: Reports edema.
RESPIRATORY: Reports shortness of breath.
ALLERGIES: Amoxicillin.

O.
Physical exam
Vital signs : BP 150/86; HR 100, RR 22 (non-labored), T 98.0 height 5’2”, weight 163 pounds,
BMI 29.8
HEENT : normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower
dentures in place a fitting well. No tinnitus. Neck supple; non-palpable lymph nodes; no carotid
bruits. Thyroid non-palpable.