Patient name: DH
DOB: 7/14 Admit Date: 8/23
Age: 65
Sex: Male
Education: Bachelor's degree
Occupation: Retired manager of local grocery chain
Hours of work: N / A
Household members: Wife age 62, well; four adult children not living in the area
Ethnic background: Asian American
Religious affiliation: Methodist
Referring physician: Marie McFarland, MD (pulmonary)
Chief complaint:
"My husband has had emphysema for many years. He was working in the yard today and got really short of breath. I called our doctor, and she said to go straight to the emergency room.”
Patient history:
Onset of disease: The patient has a long-standing history of COPD secondary to chronic tobacco use, 2 PPD for 50 years. He was in his usual state of health today with marked limitation of his exercise capacity due to dyspnea on exertion. He also notes two-pillow orthopnea, swelling in both lower extremities. Today, while performing some yard work, he noted the sudden onset of marked dyspnea. His wife brought him to the emergency room right away. There, a chest radiograph showed a tension pneumothorax involving the left lung. Patient also states that he gets cramping in his right calf when he walks.
PMH: Had cholecystectomy 20 years ago. Total dental extraction 5 years ago. Patient describes intermittent claudication. Claims to be allergic to penicillin. Diagnosed with emphysema more than 10 years ago. Has been treated successfully with Combivent (metered dose inhaler )-2 inhalations qid (each inhalation delivers 18 mcg ipratropium bromide; 130 mcg albuterol sulfate). Diagnosed with Type 2 Diabetes three years ago, treated with Janumet daily.
Home Meds: Combivent, Lasix, Janumet, O2 2 L/hr via nasal cannula at night
