Patient Encounter 1 Part 2 Medical History Physical Examination and Diagnostic Tests

The 73-year-old woman presents again to your clinic complaining of difficulty breathing and shortness of breath. Her daughter also states that she is easily confused and that this is not normal for her.

PMH: COPD for 15 years; hypertension for 4 years, currently controlled

FH: Father died of lung cancer at the age of 68 years; mother died of natural causes

SH: Smoked two packs per day for 23 years, quit 15 years ago; does not drink alcohol; lives with her daughter

Allergies: NKDA

Meds: Lisinopril 10 mg orally once daily; Ipratropium bromide four puffs four times per day; flunisolide three puffs two times per day; albuterol two puffs as needed

ROS: (+) difficulty breathing and shortness of breath; (-) chest pain, N/V/D, weight loss, change in appetite

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