Patient Information: Patient Initials: MH Age: 47 Sex: Male Race: Caucasian SUBJECTIVE DATA: CC (chief complaint): “I feel short of breath.” History of Present Illness (HPI): MH is a 47-year-old Caucasian male that came in today with complaints of shortness of breath that started getting worse 3 days ago. His shortness of breath gets worse with any activities talking, walking, and sitting. He is no longer able to lay down at night due to his shortness of breath and has developed a clear productive cough. Mr. MH states he ran out of his diuretic about 3 weeks ago. Nothing he tried at home has given him any relief, his discomfort is a 7/10. Current Medications : Lisinopril 10mg BID Amlodipine 5 mg BID Potassium 20 meq daily Lasix 40 mg daily Allergies: NKDA Past Medical History (PMH): HTN, CHF, last tetanus 2015, Influenza vaccine October 2018, Pneumonia vaccine 2015, all other immunizations are up to date. Past Surgical History (PSH): Cardiac catherization w/ 1 stent-LAD 2015 Sexual/Reproductive History: Heterosexual male Social History : Enjoys fishing, divorced, quit smoking in 2015 after cardiac catherization, he uses to drink 5 beers/day but now 1/day. He usually tries to buckle up and he never text while driving. He joined a divorce support group. Family History : Mother died at 77 emphysema Father died at 56 heart attack Grandparents unknown No siblings
No children Review of Systems: GENERAL : 5 pounds weight gain since last visit, shortness of breath, no fever HEENT:
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- Summer '15
- shortness of breath, pulmonary edema