Lower leg swelling-weight loss ? medical history

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Reference no: EM133819942

Question

Joseph Rogers (pronouns he/him/his), 82 years old ? Height & Weight: 5"11", 130 lbs (59 kg) ? Allergies: None ? Chief Complaint: Increased fatigue, lower leg swelling, weight loss ? Medical History: Hypertension, hyperlipidemia, coronary artery disease (CAD), gastroesophogeal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), hyperthyroidism ? Social History: Prior smoking history (40 years at 2 packs per day), denies alcohol use, lives with wife, retired, walks dog daily ? Family History: Hypertension (mother and father); diabetes mellitus (DM), type 1 father; mother died of myocardial infarction (MI) at age 65 ? Vital Signs: Temperature 98.8 °F (37.1 °C) oral, blood pressure 165/74 mmHg, heart rate 98 bpm, respiratory rate 18 bpm, SpO2 95% RA ? General Appearance: Appears fatigued, anorexic ? HEENT: Unremarkable ? Cardiac: S1 and S2 regular rate and rhythm, jugular vein distension (JVD), S3 gallop ? ECG: Sinus rhythm at 98 bpm ? Respiratory: Lungs clear to auscultation, diminished in bases ? Musculoskeletal: Dependent lower leg edema; +2 pitting ? Fingerstick blood glucose level: 86 Drag the findings that require immediate follow-up to the box on the right. Findings Findings That Require Immediate Follow-Up Vital signs Vital signs Lower leg edema Jugular vein distension.

Reference no: EM133819942

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