History and Physical Sample

Chief complaint : shortness of breath HISTORY OF PRESENT ILLNESS: complains of dyspnea and fatigue over the last

several months. Over the past couple of weeks, I sometimes wake up short of breath. Last night, I woke up 3 times. I cough a lot and am just so tired. I cant even walk to the mailbox without feeling extremely exhausted. My legs are starting to swell, and Ive gained 14 pounds in the last couple of weeks. Over the past 2 weeks, she c/o 3-pillow orthopnea She c/o cough without sputum and feels fatigued most of the day and cannot perform her usual activities of daily living She also noted BLE edema over the past several weeks.

PAST MEDICAL HISTORY: HTN and Coronary artery diease diagnosed at age

54; Hospitalizations: MI, 2004 Surgeries/procedures: Cardiac catheterization, post-MI, 2004

CURRENT MEDICATIONS: HCTZ 25 mg PO daily

Sotalol 120 mg PO BID Simvastatin 40 mg PO at bedtime Celecoxib 200mg BID

ALLERGIES: The patient has no known medication allergies.

Surgical History: Noncontributory Family: Mother: HTN for many years died of M.I at 67; father: died at age 65 MI. Social history: smoked and quit 10 years; 40 pack-year history. Denies alcohol use. Is a retired hotel housekeeper, lives with her husbanda retired mechanic. She has 2 grown children.
REVIEW OF SYSTEMS: Respiratory: No history of bronchitis or asthma. Cardiovascular: History of systolic murmur due to ventricular septal defect.

ROS
General Well-developed, obese white female with noticeable SOB HEENT: Head denies headache, dizziness, syncope Ears denies difficulty or changes in his hearing, denies tinnitis Eyes denies problems or changes in his vision; denies blurred vision; denies seeing spots Nose normal Throat normal Cardiovascular nl S1 and S2, point of maximal impulse (PMI) was displaced downward and laterally Pulmonary Decreased breath sounds, crackles in bilateral lower lobes Gastrointestinal normal Genitourinary denies dysuria; denies increased frequency or urgency of urination Neurologic denies numbness and tingling; denies paresthesias Muskuloskeletal denies any muscle or joint pain Endocrine not assessed Hematopoietic denies easy bruising
PHYSICAL EXAMINATION: GENERAL: Well-developed, obese white female with noticeable SOB VITAL SIGNS: BP 110/78, HR 55, RR 20, T 98.5F, Wt 70 kg, Ht 54 HEENT: denies headache, denies change in vision NECK: + JVD to 12 cm, no bruits LUNGS: Clear to auscultation with no evidence of rhonchi or rales. HEART: nl S1 and S2, RRR, S3 gallop, point of maximal impulse

(PMI) was displaced downward laterally CNS: normal

ABDOMEN: EXTREMITIES: Normal

edema to knees bilaterally