NEW 2023 JOSEPH CAMELLA "SHORTNESS OF BREATH"

NEW 2023 JOSEPH CAMELLA "SHORTNESS OF BREATH"



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


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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