Patient Presentation Definition

Lungs: Demonstrate good air entry. Faint end-expiratory wheeze throughout all lung fields. No rales or rhonchi. Symmetric chest expansion. Breathing nonlabored.

Patient is a high school counselor. He participates in physical activities by running 2 to 3 times a week, playing golf, and volunteering at a nursing home. The patient is married with one daughter and one son. He does not use tobacco and periodically drinks at

4. The patient has been taking Sudafed and wants to know if he should continue to take it. What is your response? No, the patient should not continue taking Sudafed and should eliminate it immediately. The patient has been prescribed APAP for pain and another for allergies. Sudafed is not recommended to be taken if patient has any heart related health problems.

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

The patient also tells me she uses lorazepam very intermittently. She is almost out of that medication would like a refill today. I did write her for lorazepam 0.5 mg to use p.r.n. #20 with no refills.

Situation: the patient is a 78 year old male, with chronic obstructive pulmonary disease, demonstrating restlessness, agitation with a rapid heart rate, tachycardia.

External ears, nose, and mouth appear normal in appearance, with moist mucous membranes. Neck is supple with trachea in midline. There is no cervical adenopathy noted.

Lungs: Mild end-expiratory wheezing. Pursed-lip breathing noted and has a prolonged expiratory phase. Chest x-ray shows pulmonary hyperinflation, flattening of the diaphragm; Pulmonary function test (after bronchodilation with 2 puffs albuterol—FEV1/FVC ratio 0.60 FEV1 60% of predicted value)

HPI: Pt reported feeling more anxious and depressed due to moving to a new location in Colorado. Pt reported sleeping adequately and feels he has good sleep on most nights. Pt does not exercise but goes on walks around his neighborhood once in a while. Pt reported he has been feeling down in the past but has not seen a PCP for this problem prior to last visit. Pt was started on citalopram 20 mg one-half tablet by PCP on 12/16/2015.

Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetric chest expansion. Breathing nonlabored. Diminished breath sounds in all lung fields. Resonant to percussion.

Respiratory. The client denies a recent history of significant breathing problems. Client states as a child she had asthma but that has since cleared up. She denies cough, sputum, shortness of breath with activity, wheezing, or pneumonia. Client states she has no history of exposure to tuberculosis. The client has a history of smoking. She smoked for less than a year in 2007. She states she smoked 1/20th of a pack per day and quit cold turkey. Client stated she had bronchitis once in June 2016. Her physician prescribed an albuterol inhaler and a steroid prescription. Treatment resolved the bronchitis. The client states she has limited exposure to secondhand smoke due to neighbors smoking on their front porches in the townhome apartment complex where she lives.

Social History: The patient is married and lives in Portsmouth with his wife. He has three adult children who are healthy. Following formal education, he has worked as a mechanic as well as owning various business on the Seacoast. He currently does not smoke, however has greater than 60-pack-year history of smoking. He quit nearly 30 years ago. He does drink a glass of liquor

No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,

1. Continue all medicines including Zoloft. Do not stop or alter dose by yourself unless suggested by your doctor because some diseases need lifelong treatment. All mentioned medications can

Respiratory: Lung sounds are clear on auscultation without rales, rhonchi, or wheezes. Respiration unlabored with