Step 2:
66-Year-old White Male presents to the ED with Dyspnea accompanied by his wife.
Appearance: well nourished, toxic appearance, pallor, diaphoretic.
HPI: For three days after a boating accident patient has been having chest discomfort, indigestion after coughing, thick yellow phlegm starting to smell bad, chest discomfort worse when taking a breath, deep pain in both sides of his lungs, chest hurts more at night, sitting up helps breathing, headache, sweating.
Past Medical/Surgical History: Hypertension, sleep apnea. No trauma or diagnosed lung diseases.
Family History: Mother had asthma
Social History: Beers on the lake, non-smoker
Allergies: Penicillin and seasonal allergies
Medications: Lisinopril for HTN, Zyrtec for Seasonal allergies
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HPI
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Any swelling in the feet, ankles or legs?
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Do you know if you snore, or have you been told that you snore at night?
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Headaches?
If so, do they occur more in the morning?
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Do you wake up suddenly?
If so, do you have gasping or choking with it?
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Family History
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Have your wife been diagnosed with any bacterial, viral, fungal or parasitic infections?
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Social History
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Are you employed?
If so, do you ever deal with harsh chemicals?
If you worked with harsh chemicals, did you wear a mask?
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