Evans. Week1. Soap nr601 - Patient Information L J 65 y/o...

Patient Information:
L. J., 65 y/o, Male, Hispanic
S.
CC: “ Shortness of breath.”
HPI : include all the information regarding the CC using the OLDCARTS format. If the CC was
“Unintentional weight loss”, the OLDCARTS for the HPI might look like the following example:
Onset:3 months ago
Location: Respiratory system (lungs)
Duration: Unknown
Characteristics: Worsening shortness of breath
Aggravating Factors: Daily Activities
Relieving Factors: n/a
Treatment: None reported
Severity: Pursed lip breathing
Current Medications :
Ibuprofen 600 mg po tid, (used for pain, unknown length of time)
Lisinopril 20 mg po QD (used for htn, unknown length of time)
Hydrochlorothiazide 25 mg po QD (used for htn, unknown length of time)
Simvastatin 20 mg po QD (used for high cholesterol, unknow length of time)
Meloxicam 7.5 mg QD (used for osteoarthritis, unknown length of time)
Allergies: NKA
PMHx : Hypertension, cataracts, and osteoarthritis, left knee arthroplasty in 2013
Soc Hx: 65 pack year history of cigarette smoking; denies alcohol intake or illicit drug use; is
married and recently retired.
Fam Hx : Father has history of HTN; Mother has history of “mild” stroke; Brother has a history
of hyperlipidemia.
ROS :
CONSTITUTIONAL: Denies weight loss, fever.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies
palpitations or edema.
RESPIRATORY: Reports shortness of breath, cough and sputum.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam
Vital signs : BP 138/88; HR 88 (regular), RR 18, T 98.8 height 5’7”, weight 175 pounds
CONSTITUTIONAL: No weight loss, fever.
General appearance : Thin and mildly dyspneic
Cardiovascular : S1 and S2 RRR with distant heart tones. No murmurs. No edema. All pulses
2+.