DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR REFERRAL: Evaluation of slowly progressive dyspnea with exertion.
HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old gentleman who states that he has noted, since April, slight increasing shortness of breath with activity. He mostly notices this when he is exercising or trying to climb a flight of steps or so on, but he can carry out activities of daily living without any significant distress. This patient has had no pleurisy, no hemoptysis. None of his feelings have been sudden in onset. He is snoring, apparently significantly, according to him. He gets into bed between 7:30 and 8 p.m. and gets up at least three times at night. He gets up at 5 a.m. during weekdays. He has occasional wheezing. He at present limits his activity by dyspnea. His weight is a problem, presently at 350 pounds, and he may be a candidate for bariatric surgery, according to him, and he believes Dr. John Doe is working on this. There is no significant cough or phlegm production. No fevers or chills. No PND or orthopnea. He has chronic lower extremity edema. No major changes in voice, headaches, visual problems. No nausea or vomiting. No chest pain or chest pressure.
PAST MEDICAL HISTORY: Positive for what appears to be renal stones. He states having some renal insufficiency. Apparently, the patient has a degree of increased protein loss in his urine, according to him. He has a history of hypertension and coronary artery disease. He had a cardiac catheterization six months ago.
FAMILY HISTORY: Father alive aged 74, has emphysema and coronary artery disease. Mother died aged 72 of myocardial infarction. He has some siblings who have coronary artery disease and diabetes.
SOCIAL HISTORY: The patient has never smoked. No alcohol. Positive exposure to smoke and dust.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed gentleman who is above his ideal body weight by a significant margin. Certainly, this may be playing a role in much of his symptomatology.
VITAL SIGNS: Height 5 feet 5 inches, pulse 98 per minute, respiratory rate 18 per minute, blood pressure 146/68, and saturations on room air 93%.
NECK: No JVD, adenopathy or tracheal deviations.
HEART: Presently regular. We did not appreciate any significant murmurs.
LUNGS: For the most part, clear.
EXTREMITIES: The patient does have peripheral edema.
DIAGNOSTIC DATA: No chest x-rays are available for review.
IMPRESSION:
1. This gentleman may have a sleep disturbance. We will go ahead and order an overnight oximetry. If this were abnormal, we would proceed to nocturnal polysomnography.
2. We would describe him as morbidly obese, and we need to work on that.
3. To assess his dyspnea, we will obtain a six-minute walk, full pulmonary function tests, and get the chest x-ray report from the outside hospital.
PLAN: The patient is to continue to follow with his usual medical team. We will try to get the results of his cardiac catheterization. We will keep you updated and further comments post reviewing the data as above. We reviewed his medications, and the patient is presently on no inhaled bronchodilators. We will comment further after review of pulmonary function tests.
