Evans. Week2. Soap - Patient Information B J 70 y\/o Female Black S CC Shortness of breath HPI Onset:Unknown Location Respiratory system(lungs Duration

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

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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.
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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. SKIN : Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet. Cardiovascular : Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally Respiratory : inspiratory crackles.
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  • Fall '16
  • shortness of breath, Neff, Schub

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