History (H)
Chief Complaint: Shortness of breath and productive cough.
History of Present Illness (HPI): Mr. Charlie Breather is a 65-year-old male admitted to the medical-surgical unit with a diagnosis of pneumonia. He reports significant shortness of breath with minimal activity and productive cough with thick green sputum. Oxygen therapy is being administered at 4 L/min via nasal cannula. During activity, his oxygen saturation drops to 90%. He feels “pressured to keep up” with treatments and expresses discomfort about using the bronchodilator due to side effects like shakiness. His daughter, who is his healthcare proxy, insists on continuing all treatments as prescribed.
Past Medical History (PMH):
Chronic Obstructive Pulmonary Disease (COPD)
Past Surgical History (PSH):
None reported
Family History (FH):
Father: Deceased, history of heart disease
Mother: Deceased, history of COPD
Social History (SH):
Former smoker, quit 15 years ago after a 30-year history of smoking.
Lives alone, with daughter as primary caregiver and healthcare proxy.
No alcohol or drug use reported.
Allergies: None known
Medications:
Antibiotics (as prescribed for pneumonia)
Bronchodilators (as prescribed, but patient is reluctant to use)
Oxygen therapy at 4 L/min via nasal cannula
Physical Examination (P)
Vital Signs: BP 138/82, HR 92 bpm, RR 24 (slightly labored), Temp 99.2°F, O2 Sat 94% (on oxygen 4 L/min via nasal cannula)
General Appearance: Appears fatigued but alert and oriented. Slightly pale, no cyanosis noted.
HEENT: Normocephalic, mucous membranes moist.
Cardiovascular: Regular rate and rhythm, no murmurs or abnormal heart sounds.
Respiratory: Bilateral crackles and diminished airflow in the bases. Productive cough with thick green sputum.
Gastrointestinal: Abdomen soft, non-tender, normoactive bowel sounds.
Neurological: Alert and oriented, no focal deficits.
Musculoskeletal: No musculoskeletal abnormalities noted. Normal strength and movement in all extremities.
Skin: Slightly pale, good skin turgor, no cyanosis noted.