№ files_lp_4_process_2_68639
Comprehensive clinical record detailing the patient history, physical examination, and differential diagnoses for a Haitian male presenting with progressive dyspnea, gastrointestinal disturbances, and weight loss over one year.
Date: September 4, 2019
Patient Name: Y.D.
Sex: Male
Age: 41 years old
Race: Black
Nationality: Haitian
Marital Status: Married
Occupation: Police officer
Chief Complaint: Shortness of breath
History of Present Illness: Progressive dyspnea over 1 year with recent worsening
Past Medical History: GERD
Past Surgical History: None
Medications: Docusate 100 mg BID, Pantoprazole 40 mg
Allergies: None reported
Family History: Non-contributory
Social History: Denies alcohol, tobacco, caffeine, or illicit drug use; lives with wife and children
Vital Signs: BP 134/89 mmHg, RR 18/min, P 100 bpm, T 97.5 °F, O2 Sat 90%
Physical Examination Findings: Thin, well-nourished male, erythematous macules on neck and shoulders, decreased breath sounds on right lung, low volume left lung sounds, labored breathing, heart sounds slightly displaced
Differential Diagnosis: Emphysema, pneumothorax, restrictive lung disease
Review of Systems: Weight loss 15 lb in 2 months, fatigue, constipation, dysphagia, dry cough, right-sided rib pain
Functional Status: Previously good exercise tolerance, now dyspnea at rest
Referral Source: Self
Competency: Competent and reliable
Source of History: Self
Document Type: Medical evaluation report
Intended Use: Clinical reference for diagnostic assessment
Price: 8 / 10 USD
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