Joseph Camella "Shortness of Breath" case study

Patient Information: MH, 68, Male, White American S. CC: “Shortness of Breath” HPI: The patient is 68 year old WA male with a shortness in breath. The shortness of breath is described to be experienced all the time and worsens at night. The shortness of breath is accompanied by a cough that continues throughout eh night. The patient reports swelling in the abdomen and legs as well as an increase in weight by five pounds. The patient was prescribed fluid pill for the swelling. Current Medications: No medications. Allergies: No cases of allergies reported. PMHx: Positive medical history. Soc Hx: Negative for tobacco and alcohol use, married for 43 years. Fam Hx: Father died at 80 of heart attack, mother at 75 from severe chest pain. No history of cardiovascular illnesses from other family members. This study source was downloaded by from CourseH on :16:06 GMT -05:00 SHORTNESS OF BREATH 3 ROS: GENERAL: five pond weight gain. HEENT: No rhonchi or wheezes. SKIN: Cool and dry skin. CARDIOVASCULAR: No chest pain or chest discomfort. Positive for peripheral edema RESPIRATORY: Cough, clear flem. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: No burning on urination. NEUROLOGICAL: No headache or dizziness. Presence of normoactive bowel sounds. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. This study source was downloaded by from CourseH on :16:06 GMT -05:00 SHORTNESS OF BREATH 4 Physical exam: Five pound weight gain, temperature of 97.9, respiratory rate was 22, Heart rate was 94, blood pressure 162/90 and the oxygen saturation was 92%. The patient’s thorax was symmetrical with breath sounds that were vesicular. A regular heart rate with good S1 and S2 sounds and S3 extra heart sound was reported. Systolic murmur was 3 out of 6. Abdomen was distended. Three plus peripheral edema extended to the knees bilaterally and dorsalis pedis pulses palpated bilaterally. Diagnostic results: EKG, Chest X-ray