Full code history of present illness

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Patient Information Name: John Smith Age: 68 years Gender: Male Medical Record Number: 123456 Admitting Diagnosis: Congestive Heart Failure (CHF) Weight: 90 kg Height: 175 cm Allergies: None known Code Status: Full Code History of Present Illness John Smith was admitted to the hospital with shortness of breath, swelling in his legs, and rapid weight gain over the past week. He reports that he has been feeling increasingly fatigued and has been unable to lie flat without feeling like he is suffocating. He has a history of congestive heart failure, hypertension, and type 2 diabetes mellitus. Medical History Congestive Heart Failure (CHF) Hypertension (HTN) Type 2 Diabetes Mellitus (T2DM) Chronic Kidney Disease (CKD) - Stage 3 Medications Furosemide 40 mg PO BID Lisinopril 20 mg PO daily Metformin 500 mg PO BID Carvedilol 25 mg PO BID Insulin glargine 20 units subcutaneously at bedtime Social History Smoking: Quit 10 years ago (smoked 1 pack per day for 30 years) Alcohol: Occasional use Occupation: Retired accountant Living Situation: Lives with his wife in a single-family home Physical Examination General: Alert, oriented to person, place, and.

Reference no: EM133747783

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