Episodic/Focused note Case Study #2Patient Information:Patient: Mr. HAge: 65Sex: MRace: CaucasianCC: Shortness of BreathSUBJECTIVE: HPI: Mr. H arrives at the office today with a complaint of shortness of breath for past two days that has been getting worse. He states, “I wish I could get a deep breath”. He reports chest pain that is “sharp”, and it feels like his “heart is racing”. His wife mentioned to him that his right lower leg was swollen and Mr. H reports pain and redness; however, he denies any injury. Mr. H reports an eight-hour plane ride from a recent vacation. The severity of his pain is a 6/10 on the pain scale for his chest and 3/10 for his leg.Current Medications: No medications to list currentlyAllergies:No known allergiesPMH:No significant PMH to note. He is up to date on her immunizations.Social Hx:Mr. H reports he is a smoker. He drinks an occasional beer. He wears his seatbelt while in a vehicle and does not use a cell phone while driving. He enjoys traveling with his wife.FH:He has no health history to reportROS:GENERAL:Denies weight loss or fever. Reports “feeling tired all the time”HEENT:Eyes – denies blurred or double vision, glaucoma, or photophobia, and his last eye exam was six months ago. He wears eyeglasses. Ears/Nose/Throat-denies hearing
loss, ear infections, or tinnitus. He denies a runny nose and a sore throat. Sense of smell is intact. No polyps, infection, or epistaxis. No gingivitis, sores, or bleeding noted. Does not wear dentures. Denies difficulty chewing or swallowing.