65 Years old male patient came to the clinic with the complaint of:
• Chief complaints: Shortness of breath,
• HPI: 65 years old male presents with acute on chronic shortness of breath. Patient
endorses 1.5 weeks of s
...
65 Years old male patient came to the clinic with the complaint of:
• Chief complaints: Shortness of breath,
• HPI: 65 years old male presents with acute on chronic shortness of breath. Patient
endorses 1.5 weeks of shortness of breath. Other associated symptoms include chronic
productive sputum (yellow), chills, nausea, upper abdominal pain related to coughing,
, chest pain with coughing. Denies emesis, diarrhea, headache, dysphagia, myalgia
• Past Medical History: Patient have the history of COPD on O2 at 2 LPM, Hypertension,
Hyperlipidemia. No history of surgeries in the past.
• Allergy Identification: Patient denies any food, drug, seasonal or latex allergies.
• Medication Reconciliation: Patient Takes Albuterol 90MCG oral inhale 2 puffs every
four hours as needed for SOB, Olodaterol/Tiotropium 2.5mcg/actuat 60 D 2 puffs daily
for COPD. Guaifenesin 100mg/5ml takes 10 ml Q 6 hours as needed for cough.
Atorvastatin Calcium 40 mg tab once a day in the evening for hyperlipidemia, Losartan
50 mg one tab once a day for hypertension.
• Social History: Patient denies use of smoke, or any illicit drugs. Used to drink alcohol
but quit drinking two years ago. Lives with daughter and grandson. Enjoy reading books
and watching TV in his free time.
• Family History: Father died at the age of 85, had the history of prostate cancer and
hypertension, Mother died at the age of 74, had the history of arthritis and hypertension.
Younger sister is alive and have asthma.
• Heath promotion: Patient’s last follow up with his PCP was six months ago. Last eye
and dental exam were lats year in December. Eats healthy heart diet. Goes for walk about
once a week for 40 minutes, otherwise does not do any exercises. Retired Navy officer.
Checks his Blood pressure once a week and keep log of the numbers. Patient uses rolling
walker for long distance walking and cane for around the house. he reports being up to
date on vaccines including flu and pneumonia vaccine and received both shots for
COVID 19. He wears his mask when he goes out in public and maintains a physical
distance of six feet while practicing good hand hygiene
ROS:
• General: The patient denies fever, fatigue, weakness, weight gain or weight loss.
• Head, Eyes, Ears and Throat: Eyes – The patient denies pain, redness, loss of vision,
double or blurred vision, flashing lights or spots, dryness, the feeling that something is in
the eye and denies wearing glasses. The patient denies ringing in the ears, loss of hearing,
nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue,
bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or
removable dental work, frequent sore throats, hoarseness or constant feeling of a need to
clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or
throat, food sticking in throat when swallows or painful swallowing.
• Cardiovascular: The patient denies chest pain, irregular heartbeats, sudden changes in
heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or
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