Medical Report

Medical Report

  • Submitted By: igolka
  • Date Submitted: 02/08/2014 9:10 AM
  • Category: Science
  • Words: 1103
  • Page: 5
  • Views: 71

Louie Sanchez

Date: 11/04/03

Identifying data:
Age: 33
Sex: Male
Occupation: Restaurant dishwasher
Reliability: Good

Chief Complaint: cough, fever, shortness of breath

HPI: Mr. Louie Sanchez is a previously healthy 33 year old Hispanic male who presents to the emergency room on the day of admission with a five day history of subjective fever, chills, dry cough and shortness of breath. The patient complains of progressive dyspnea on exertion over the past five days such that he is now unable to climb one flight of stairs without becoming severely dyspneic. His cough has been non-productive and he has had no hemoptysis. He has no prior history of pulmonary or cardiac disease and is a non-smoker. He has no complaints of rhinnorea, sore throat, ear pain or sinus pain. He denies recent weight loss, night sweats, or chills, though he has felt warm for several days. His appetite has been generally good, but he has noted a decrease in his energy level. He denies orthopnea, paroxysmal nocturnal dyspnea or peripheral edema. He has no other symptoms of infection such as myalgias, dysuria, nausea, vomiting or diarrhea. He has no recent travel outside of San Diego and does not know of any TB exposures. He does note that he was exposed within the past week to some cleaning materials at his work that caused a red, itchy rash on his hands which has since resolved.

Childhood Illnesses: Recalls chicken pox, does not recall any others
Adult Illnesses: None
Surgeries: None
Trauma/Hospitalizations: None
Medications: None
Allergies: no known medication or environmental allergies
Transfusions: None
Exposures: see HPI, otherwise no known exposure to asbestos or other hazardous materials

M 56 alive and well, no major medical illnesses
F unknown, no contact for 20 years
No siblings or children
No known family history of diabetes, heart disease, hypertension, or cancer

Mr. Sanchez lives with his mother in an...

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