Name: Margaret Elliot Dob: 1/22/65 Sex: Female Date: 1/22/65..
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Name: Margaret Elliot DOB: 1/22/65 Sex: Female Date: 1/22/65 CC: “severe shortness of breath”
HPI: Margaret Elliot is a 52-year-old Caucasian female that is presenting with shortness of breath that has recently worsen. Mrs. Elliot states that her problems began 20 years ago when she had bronchitis, which she consistently has 2-3 times a year. She said that her symptoms have been getting worse the last 2.5 month, but have severely worsen over the past three days. She states that it has been restricting her daily activities and has been troubling her while sleeping lying down. She states that her symptoms improve alittle when she takes her medications. She also states that her symptoms worsen when she tries to walk across the room…show more content… She states that she recently has been having headache which she believes is from a nicoderm patch. Denies night sweats, fever, appetite changes, polydipsia and dizziness.
HEENT: Denies double vision, visual acuity changes, sore throat, dysphagia, rhinorrhea, tinnitus, dry mouth. Denies lymph node enlargement.
Respiratory: SEE HPI
Cardiac: Mrs. Elliot states she has experienced chest pain 5-6 times starting three weeks ago when she is Short of breath. The pain she said is on the left side of chest and describes is as sore and uncomfortable. Additionally, the patient has experienced palpitations the past few weeks and is positive for peripheral edema. Denies redness, cyanosis, jaundice, flushing.
GU: Denies nocturia, dysuria, urinary frequency or urgency
Musculoskeletal: Patient denies muscle weakness and joint pain
Neuro: Denies numbness, weakness, paresthesia
Skin: Denies sweat disorder, skin changes, Raynaud
Psych: The patient states that she is depressed due to “falling apart” and anxious about dying. Denies suicidal thoughts, memory loss and confusion.
General Survey: The patient was alert, oriented and breathing rapidly
Vitals: 5’3” Weight: 110lbs BP: 90/70mmhg HR: 88 regular, Temp: 99.1, pulse Ox: 92%
HEENT: No thyroid enlargement, masses or adenopathy, JVP was 5 cm above sternal Angle, carotid pulse was strong and regular
Respiratory: Inspiratory and expiratory wheezing was heard bilaterally, crackles in