Review of Case Study #1 Patient Information: Name: JH Age: 60 Sex: Male Race: Caucasian S. CC: “I am having shortness of breath; I am tired all the time and not feeling so good” HPI: 60-year-old Caucasian male presents to the clinic today experiencing SOB and not feeling well for the past four days. Over the last four days, he has experienced shortness of breath walking from room to bathroom. He has noticed swelling in his abdomen and legs. He has been sleeping in a recliner past four nights and states he is unable to lay flat in bed. He has a productive cough with clear phlegm. He noticed increased shortness of breath form just talking. He claims nothing seems to make it better. He stated he is on a fluid pill but ran out three weeks ago, and didn’t get it refilled because it keeps him up all night going to the bathroom. He denies chest pain, pressure or tightness. He noticed his pants are tighter and swelling in his abdomen and he stated he had gained five pounds from his last visit. Current Medications: • Lasix 80 mg by mouth daily (hasn’t taken for three weeks) • Plavix 75 mg by mouth once daily • Metoprolol 75 mg by mouth twice daily • Lipitor 80 mg by mouth once daily • Nitroglycerin 0.3 mg sublingual every 5 minutes as needed, up to 3 doses in 15 minutes Allergies: Sulfa- Rashes. PMHx: Mr. Hendrix has a medical history of MI (2011), CHF (2012), Hypertension (2010), and hx of chicken pox. Past Surgical History (PSH): Patient has a surgical history of CABG 3-vessel (2011) and Right inguinal hernia repair (2000).
Soc Hx: Mr. Hendrix is a heterosexual male married to the same woman for 35 years living in a rural area. He retired from a construction job five years ago. Receives a monthly retirement pension, has good medical, dental, and vision insurance. He states wife and children are very supportive. He states that he is sexually active with the wife. He denies a history of STDs/STI. He has a 30 pack/year smoking history. States he has cut down to 3 cigarettes/day. Denies ETOH or illicit drug use. Walks one mile daily until two weeks ago, before the visit. Immunization History: • Flu and Pneumonia vaccine 2017 • Tdap vaccine in 2014 • Zostavax vaccine in 2015 Fam Hx: • Father died at 50; cause of death unknown • Mother alive and well at75 with osteoarthritis • Son has no significant health history • Daughter age 41 with history breast cancer ROS: General: Easily fatigued, 5-pound weight gain this week. Denies recent fever, chills, or night sweats. He denies any syncope.
- Summer '15
- shortness of breath