Worsening shortness of breath and chest congestion

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Reference no: EM133796622

Question

A 66 y.o. man presents to his primary care provider for worsening shortness of breath, chest congestion and symptoms of severe cold (cough, runny nose, nasal congestion, drowsiness) over the past week. His past medical history is significant for heart failure, hypertension and hyperlipidemia. His current medications include lisinopril 20 mg daily, simvastatin 40 mg daily, furosemide 40 mg daily and potassium chloride 20 mEq daily. The patient reports sporadic compliance with his prescribed medications and also admits to taking several over-the-counter (OTC) medications over the past 5 days for his cold symptoms, namely Alka-Seltzer Plus Cold Formula (2 tablets every 4 hours during the day), Sudafed Congestion (60 mg every 6 hours), and Advil PM (2 tablets at bedtime). His social history is significant for alcohol use (3-4 beers/night). Vital signs: afebrile, BP 172/94, HR 84, RR 16. On exam he has an S3 gallop, inspiratory rales bilaterally, and 3+ pitting edema in both lower extremities.

Reference no: EM133796622

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