S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months.
Cyclobenzaprine 10 mg prn
Meloxicam 15 mg daily
Metoprolol 25 mg daily
Spiriva HandiHaler daily as directed
Tramadol 50 mg daily prn
Appendectomy as a child (date unknown)
2004-Left cataract extraction with intraocular lens placement
2008-Right cataract extraction with intraocular lens placement
Influenza vaccine- October 2013
His last TD-canâ€™t remember
Has not a TDAP/TD in 20 years
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to Â½ pack cigarettes daily. Has smoked for 45 years total.
Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer.
Discussion Part One: