Mr. B is a 75-year-old, white, male
Source: Self, reliable source
Chief complaint: “I feel winded.”
HPI: Patient states he has been feeling short of breath with exertion for years now. However, over the past year he feels he has been worsening. He decided to come in today as he experienced shortness of breath mowing his lawn yesterday and had to take two breaks. He has a cough, generally productive. He denies any chills or fever. He denies any chest pain or lower extremity swelling. He denies any nausea or vomiting. He has not taken anything OTC for his symptoms.
Lisinopril, 20 mg, daily
Propranolol ER, 120 mg, daily
Simvastatin, 40 mg, daily
Aspirin, 81 mg, daily
Tamsulosin, 0.4 mg, daily
Sertraline, 100 mg, daily
Omeprazole, 20 mg, daily
Metformin, 1000 mg, BID
Glimepiride, 4 mg, daily
Insulin glargine, 10 units, nightly
Pertinent History: Hypertension, hyperlipidemia, diabetes mellitus, benign prostatic hyperplasia, anxiety, gastritis, obesity, nicotine dependence
Health Maintenance. Immunizations: Immunizations up to date, to include PPSV-23. He has refused recommended yearly low dose CT screens (candidate given at least 30 pack-year-smoking history).
Father – Congestive heart failure, hypertension, hyperlipidemia (deceased age 81)
Mother – atrial fibrillation (deceased age 79)
Social History: Patient lives with his wife. He smokes 1ppd (40 pack year history). He drinks “a beer or two a day” and denies drug use.
ROS: Incorporated into HPI
VS – BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 340 lbs, height: 64 inches.
Mr. B is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age.
Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop. No peripheral edema or jugular vein distention
Respiratory: Clear to auscultation, but decreased breath sounds
Chest x-ray shows no consolidation or masses
ECG shows sinus rhythm
Spirometry shows FEV1/FVC < 0.7 and FEV1 of 65% predicted
Diagnosis: Moderate chronic obstructive pulmonary disorder, ICD-10: J44.9
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