Littlejohn 12 Medical Terms
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University of West Florida *
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3535
Subject
Medicine
Date
Apr 3, 2024
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docx
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1
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Paris Littlejohn RESPIRATORY SYSTEM - HISTORY & PHYSICAL EXAMINATION PATIENT NAME: Randy BURNS AGE: 56 DOB: July 2 SEX: Male ATTENDING PHYSICIAN: Joyce Mathers, MD, Pulmonology HISTORY: This 56-year-old male is presenting with a 2-week history of worsening dyspnea not associated with exertion. The patient states that he does not have to exert ' himself for his breathing to get difficult. He feels that “he cannot get his breath” sometimes even with lying in bed. He does report developing a cold and runny nose over the last 10 days, but the worsened breathing seemed to have started a few days earlier than this. He reports that the shortness of breath ¥ has progressively gotten worse in the past 2-3 days. Patient does notreport any leg or foot . edema ¢ . PAST HISTORY: The patient has a life history of asthma triggered by environmental allergens ' - grass cutting, trees budding in the spring, street dust etc. He has used a puffer when he has symptoms since he was a child. He has a history of congestive heart faillure ¢ (CHF) and sleep apnea + for which he uses a CPAP machine nightly. PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient appears laboring in breathing. He is quite distressed. VITAL SIGNS: Temperature 97 .1, pulse 88, blood pressure 121/86, weight 209 pounds, height 5 feet 8inches. HEENT « : Eye exam PERRLA. Normocephalic, atraumatic. Moist mucous membranes ¢ . No oropharyngeal erythema « . No signs of infection. Tongue is coated but tonsils are clear. NECK: Supple. No lymphadenopathy. No bruits. LUNGS: There is marked wheezing on = inspiration « bilaterally. Some minimal evidence of consolidation in the lower lobes + Dbilaterally. No rales or rubs. CARDIAC: Irregular rate and rhythm, variable S1 and S2. EXTREMITIES: Some pedal and ankle . edema « noted in low extremities. No cyanosis or clubbing. ASSESSMENT AND PLAN 1. Acute shortness of breath with a history of allergic. asthma ¢ . Rule out upper respiratory infection (URI). Will order chest x-ray stat. 2_ Atrial fibrillation. Patient has a controlled rate. Will administer one dose of Lovenox overnight. 3. Mild symptoms of CHF due to lower extremity edema. Will administer Aldactone to bring this under control. Will. monitor « the patient’s diuretic volume. 4. Plan to admit patient overnight for observation to await stat CXR result and to monitor the effects of diuretic ¢ and anticoagulant therapies. Joyce Mathers, MD, Pulmonology
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