Advanced HA Week 7 Discussion.docx - Patient Information Initials M.H Age 62 Sex Male S CC \u201cI have been having shortness of breath over the last few

Advanced HA Week 7 Discussion.docx - Patient Information...

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Patient Information: Initials: M.H. Age: 62 Sex: Male S. CC “I have been having shortness of breath over the last few days and I feel tired all the time.” HPI : The patient is a 62-year-old male who presents with shortness of breath at rest and with exertion which began a few days ago and states “it’s getting worse.” He states the shortness of breath gets worse at night, he is unable to lie flat and has been sleeping in a recliner for the past few nights. He complains of a productive cough with clear sputum all night long. He states he has gained 5 lbs. in the last week with visible swelling in his legs. He denies any associated chest pain or discomfort. He states his symptoms have not been relieved by anything. He admits he ran out of his “fluid pill” 3 weeks ago and did not get a refill due to having to urinate so often and wanted to see how he did without taking the medicine. Allergies: NKDA Medications: Pepcid 20mg po daily, Centrum Silver vitamin po daily PMH: Positive history of GERD and hypertension, which he states is controlled FH: Mother who is 88 and living has htn and congestive heart failure, Father died at 68 of an embolic stroke, His grandparent’s history is unknown, and he has no children. SH: Reports has been trying to quit smoking cigarettes recently and is down to three cigarettes a day, he denies any alcohol or illicit drug use. He is a retired restaurant manager and lives a relatively sedentary lifestyle other than plays golf once a month with his friends. He is married with no children. He states his diet usually consists of eggs and bacon in the morning with coffee, some type of meat and starch with lunch, and whatever his wife makes for dinner with a cup of coffee after. He usually sleeps 8-10 hours a night except for the last few days. ROS: General: Recent fatigue. Denies fevers or chills. 5lb weight gain in the last week. HEENT: Eyes: wears glasses. Ears, Nose, Throat: No hearing loss, sneezing, or, runny nose. Cardiovascular: Positive for orthopnea. Positive for recent bilateral lower leg swelling. Denies any chest pain, discomfort, or palpitations. Gastrointestinal: No change in appetite despite 5lb weight gain. Denies abdominal discomfort or change in bowel pattern. Pulmonary: Positive for shortness of breath at rest and on exertion. Positive for a productive cough particularly at night with clear sputum. Negative for hemoptysis. Last PPD negative 2 years ago. Up to date on flu vaccine, denies ever having PNA vaccine.
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  • Summer '15
  • productive cough, Dains

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