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11/24/10 1:10 PM

Mr. G is a 67-year-old retired Air Force Mechanic

History taken by medical students Eric Tee and Marc Huh

Chief Complaint: Difficulty breathing

Present Illness: Mr. G experienced shortness of breath 1 week ago. He said that he had spent

most of the night awake and coughing. Currently, the shortness of breath lasts for about 10

minutes. The patient reports that the shortness of breath has progressively worsened over the

past year. There is difficulty breathing with activities such as getting up from the hospital bed

to go to the bathroom and walking from the parking lot to the entrance. Patient stated that he

almost collapses. He coughs often at night and can hardly sleep. It produces a white foamy

mucus sputum. Mr. G stated that he has COPD and takes two shots of albuterol and this

seems to relieve his episodes. Also, sitting down seems to relieve his shortness of breath.

Medications: albuterol, steroids, for all others see list

Allergies: Demerol

Past Medical History: About 7-8 months ago, Mr. G complained of headaches and came down

with shingles on the right side of the face. This outbreak started at the top of the head and

progressed to the temporal region, then the cheek region, and then ended in the gums of the

mouth all within a few days. About 3 weeks ago, patient became completely blind in the left eye.

Smokes 1 pack per day since teenager and has COPD. He states that he wakes up with a

hacking cough at night and it has been bothering his wife. Patient also wheezes and the cough

produces a white foamy mucus. No hemoptysis. No chest discomfort or pain. Patient has

hypertension, and in 2002, had surgery to correct man aortic aneurysm. Currently waiting forresults of a brain aneurysm. Patient also has edema in both feet.

Family History: Mother died of aneurysms at age 81, unknown of what type of aneurysm.

Father died of food asphyxiation, but was also a smoker and had COPD symptoms. There are

no heart problems, strokes, diabetes, kidney complications, cancer, or asthma.

Social History: He is a retired mechanic for the Air Force. He worked for about 30 years. He

has a wife at home. Hobbies include leather craftsmanship. He also has 2 dogs and has

not travelled recently. Patient states that he eats anything he wants, and his weight has not

changed recently.

Alcohol: Drinks occasionally.

Tobacco: 1 pack per day since a teenager.

Review of Systems

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General: There has been no weight change. No fever or chills. He is weak and fatigued due to

the difficulty breathing. When patient changes from sitting to standing or walking up a flight of

stairs, he feels as though the room is spinning. This lasts for about 60 seconds.

HEENT: Has headaches and brain aneurysm . No head injuries besides the shingles (left some

scarring). Eyes - He does have vision problems. He was at the eye clinic 8 months ago and hasnoticed that his eyes have been red/yellow/clear. His left eye is completely blind. There are no

flashing lights. Ears - Major hearing loss and tinnitus from his occupation. Uses hearing aids.

Nose - some nasal congestion, minor seasonal allergies, no nose bleeds itchiness, discharge.

Mouth - hoarseness from cough, no dryness or sores.

Cardiac: See PMH

Respiratory: See PMH.

Urinary: No changes in urination habits.

Musculoskeletal: No complications.

Psychiatric: He feels anxious and has been depressed in the past. Sleep and mood have been

affected.