History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnoses
Relevant Testing
Test Results 1
Test Interpretation
Diagnosis 1
Relevant Next Steps 1
Test Results 2
Diagnosis 2
Relevant Next Steps 2
Test Results 3
Diagnosis 3
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Shortness of breath in a 68 y/o man
Review of Systems
General
: Patient feels generally fatigued. No fever, night sweats, or chills.
Skin
: No rash, bruising, or other skin lesions.
HEENT
: Sensation of fullness in the mouth. No vision changes, sore throat, or nasal congestion.
Pulmonary
: See HPI
Cardiovascular
: See HPI
Gastrointestinal
: Mild decrease in appetite. No abdominal pain or change in bowel habits. No diarrhea. No dysphagia or odynophagia.
Genitourinary
: Erectile dysfunction; no increased urinary frequency or urgency.
Musculoskeletal
: Bilateral painless swelling of both lower extremities below the knee for several weeks.
Neurologic
: Occasional dizziness upon standing and an episode of syncope a few months ago. No focal weakness, numbness, or tingling in his extremities.
Psychiatric
: Noncontributory
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