Shortness of breath in a 68 y/o man

Physical Examination

  • General appearance: Thin male who appears fatigued and older than stated age; in no apparent respiratory distress.

  • Vital signs:
  • Temperature: 36.8° C
  • Pulse: 77 beats/min, regular
  • BP: 92/64 mm Hg
  • Respirations: 16/min
  • Pulse oximetry: 96% on room air

  • Skin: Cool, dry, soft. No rashes, cyanosis, petechiae, or lesions.

  • HEENT: Sclera anicteric. Mild macroglossia without surface discoloration or masses.

  • Neck: Normal carotid upstrokes. Jugular venous distention 12 cm above sternal notch at 45°.

  • Pulmonary: Dullness to percussion and decreased breath sounds at the base bilaterally. Bibasilar crackles and faint end-expiratory wheezing.

  • Cardiovascular: Regular rate and rhythm. S1 soft, S2 normal, S3 at the apex. 2/6 holosystolic murmur heard best at apex. PMI not displaced.

  • Gastrointestinal: Soft, nondistended, nontender, bowel sounds in all quadrants; liver nontender, span 15 cm.

  • Genitourinary: Unremarkable

  • Musculoskeletal: 2+ pitting lower extremity edema to the thighs bilaterally with no erythema, venous distention, warmth, or tenderness. Full range of motion.

  • Neurologic: Unremarkable

  • Mental status: Alert and oriented to person, place, and time.