Wednesday, May 6, 2020

Personal Narrative Dyspnea On Exertion - 782 Words

CC: Dyspnea on exertion. History of Present Illness: Mr. Siegel is a very pleasant 80-year-old gentleman with end stage renal disease, previously on dialysis. He is here today for a formal evaluation of progressive dyspnea on exertion that has been worsening over the last six to eight months. He states that while sitting still, he has no shortness of breath. However, with any exertion at all, he does become winded very quickly. He does note some wheeze with exertion as well as cough. Interestingly there is some association with belching, which was evaluated by GI with a negative workup. He does complain of some chest tightness, as well. Per Ira Schwartz, s MD note, cardiology evaluation of his ongoing dyspnea is not primarily related to his heart. PMH: 1. History of cerebrovascular accident. 2. Hypertension. 3. Mild dementia. 4. Depression. 5. Progressive dyspnea on exertion. 6. Gastroesophageal reflux disease. 7. Chronic kidney disease, stage 4. 8. History of prostate cancer. 9. History of mitral valve regurgitation and cardiomyopathy with last recorded EF of 45-50%. 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

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