Dyspnea Case Summary

CC: Dyspnea.

History of Present Illness: Mr. Hebert is a very pleasant 60-year-old gentleman who was referred from the Naval Shipyard clinic for the evaluation of dyspnea. At the present time, Mr. Hebert feels well, however throughout most of the summer, he stated he had been complaining of a persistent cold that manifested primarily with nonproductive cough, plus and minus wheezing but was most disturbed by his conversational dyspnea. He was prescribed Advair and found near immediate relief within three to four days. A chest x-ray was also obtained which did not show any acute focal infiltrates, however it did show low lung volumes. At the present time, he states he is completely asymptomatic. He recently hiked Mount Major without difficulty and he is exercising on his treadmill on a daily basis, as well. He has no history of asthma, nor does he have any history of COPD

PMH: Hypertension.

Social History: The patient is married. He currently lives in Newington, New Hampshire with his wife. He does not have children. He currently is retired, however following formal education he did work in the military with electronics and retired as a Lieutenant Colonel. He denies smoking. He does occasional drink one to two beers on a monthly basis. He has no exposures to animal dander.

Medications:

1.

Denis 's constellation of symptoms and marked improvement following the initiation of inhaled corticosteroid and long acting bronchodilator would indicate that he may have some degree of reactive airways disease with reversible airflow obstruction. I suspect that this was precipitated an antecedent upper respiratory infection. Given the fact that he is completely asymptomatic at this time, I would advocate watchful waiting, rather than further diagnostic texting. Should he have recrudesces of his symptoms, certainly we can further evaluate with full pulmonary function testing vs a repeat trial of inhaled steroids and