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Running head: 6512_DB716512_db7Walden University
6512_DB726512_dbPatient Information:J,H, 60 y/o Caucasian MaleS.CC: “I’m not feeling so good. Shortness of breath is getting worst and I feel tired all thetime.” HPI: Mr. Hendrix is a 60 y/o Caucasian male who is complaining of shortness of breath (SOB). The initial onset of this SOB was three days ago. The patient states that his SOB is worsened with minor activity such as walking. He also states that nothing relieves it. SOB is worst at night, JH is unable to lie in bed he sleeps in the recliner. J, H denies any chest pain.Patient reports coughing at night with clear secretion production. He also complains of being tired all the time. Reports swelling in abdomen and legs and a 5 lb weight gain. Reports not taking his prescribed diuretic because of frequency in urination that makes him uncomfortable. Current Medications: Lasix 40 mg PO q DailyAllergies: No known drug allergies PMHx: HTN, DM II, CHF. Reports being up to date on immunizations to include his flu shot this year. Denies surgeries or previous hospitalizations.Soc Hx: Mr Hendricks has been married for 36 years, with 2 children ages 30 and 34. Denies alcohol consumption; reports smoking 3 cigarettes per day; is attempting to quit smoking. He is a retired accountant and enjoys the outdoors. Denies cell phone use while driving, and reports using the seatbelt regularly. He reports eating a heart-healthy diet.Reports having difficulty sleeping in his bed because of the difficulty breathing has been sleeping in his recliner.
6512_DB73Fam Hx: Mother died at 88 from heart disease; Father died at 74 from complications ofCOPD. He has one male sibling age 70, with hx of HTN and DM II.ROS: GENERAL: AAO X 4, well groomed. Denies fever chills and weakness. Reports weight gain of 5 pounds in one week.HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.SKIN: Denies rash or itching.CARDIOVASCULAR: Denies chest pain, pressure, or discomfort. Denies palpitations. Reports swelling in his BLE and Abdomen. No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY: Reports shortness of breath, and dyspnea on minimal activity to include walking and talking. Shortness of breath is continuous, and worse at night; positive for cough with clear secretions.