Pericarditis Case Studies

History and Physical Write Up #1
Student: Brandon Burt
Date of History: 1/13/2016
Patient: L.S.
CC: “I ran out of breath. I couldn’t breathe.”

History of Present Illness:
Mr. S is a 75yo white male who was in his usual state of health, which enables him to lead a relatively active life, until early Monday morning (1/11/16). At about 4am he began painting a room, a project he says he just had to finish. He was using a paint-roller and would roll paint for about 15 minutes at a time, before having shortness of breathe and feeling faint. His SOB was alleviated with sitting down and resting for several minutes. After he regained his breath he would continue painting. He repeated this cycle about 4-5 times before he “ran out of breath.” He attempted

Hematopoietic:
Denies leukemia, hemophilia, bruising or bleeding disorders.
Musculoskeletal:
Confirms joint pain, swelling, stiffness and arthritis of the left wrist and both knees
Neurological:
Confirms general weakness, occasional paresthesia and anesthesia of fingertips. Denies convulsions, seizures, sensory changes, tremors, paralysis or memory difficulties.
Psychiatric:
Confirms history of depression. Denies recent mood changes, suicidal thoughts or attempts, anxiety, tension, stress, nervousness, sleep disturbances, paranoia, auditory or visual hallucinations, delusions, phobias, obsessions or compulsions.

Physical Exam:
Vitals - T 97.8, HR 72, BP 108/60 supine, RR 18 unlabored, height 6 ft., weight 133 lbs., BMI 18.04,
General - Thin, alert, elderly white man who is sitting up on the bed breathing comfortably and appears to be in no acute distress.
Skin - Warm, pale, and dry with poor skin turgor
Head - Normocephalic
Eyes - PERRLA
Ears - both ear canals impacted w/cerumen
Nose - nares patent w/o edema or