Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.Denies any nausea, vomiting, diarrhea, or blood in stool.Self treats for occasional right knee pain with OTC Ibuprofen.Denies any genitourinary symptoms.Vital SignsB/P 190/120, HR 73, RR 18, T. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.MedicationsZyrtec 10 mg dailyAllergiesPenicillinROSStates that his overall health has been fair to good during the past year.Weight has increased by approximately 30 pounds in the last 12 months.States he has been having some occasional chest pressure and headaches for the past 2 days. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He drinks several beers every evening after work to relax.
He has smoked a pack of cigarettes a day for the past 15 years. The patient is an air traffic controller at the local airport. Hypertension Case Stud圜.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.PMHAllergic RhinitisDepressionHypothyroidismFamily HistoryFather died at age 49 from AMI: had HTNMother has DM and HTNBrother died at age 20 from complications of CFTwo younger sisters are A&WSocial HistoryThe patient has been married for 25 years and lives with his wife and two children.
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