Subjective CC: Case 2 “Short of Breath” HPI: Mr. Hendrix is a 70-year-old white male with a positive history of smoking, who developed shortness of breath over the last three days. He states that he has been feeling “tired all the time.” He also states that he has constant chest pain that is “worse and really sharp” when taking a deep breath. Cough and blood were reported in sputum. He was recently on vacation where he was on an eight-hour plane ride. He reported swelling in his right leg as well as pain and redness. PMH: Current smoking history, unknown additional history FH: Unknown SH: Positive smoking history ROS: General —Negative for fevers, chills, fatigue, night sweats, or weight loss or gain. Cardiovascular —positive for chest pain, palpitations, edema right leg, and exercise intolerance. Pulmonary —Positive cough with blood in the sputum, shortness of breath on exertion, and pleuritic chest pain. Negative for night sweats, exposure to TB, shortness of breath, dyspnea, Musculoskeletal: Heat and swelling in right lower extremity Objective VS: BP 148/88; P 112; R 32 labored; T 97.9 Oral; 02 90% on room air, Wt. 210lbs, stable General —Pt appears anxious and diaphoretic Skin— Cool, diaphoretic
Lungs and Thorax— Labored breathing; Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds in the left lobes.
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- Summer '15