Health Assessment

Chief complaint: Cough and shortness of breath Past Medical History: Sleep apnea, hyperlipidemia, Diabetes Mellitus type II, COPD, smoker for over 50 years, has quit for 1 year Past Surgical History: Appendectomy, Right hip surgery Pre-admission Medications: Prednisone, Doxycycline, Advair, Privastin, Mirapex, ASA, Oxybutinin Allergies: Penicillin Pleasant well groomed 58 y/o female lying in bed denies c/o pain. Alert and oriented x 3. Eyes blue PERRLA. Blue tinged lips. Dry non-productive cough. Lung sounds are diminished with crackles bilaterally. RR 18 regular. Dyspnea on exertion. HR 98 regular. Radial pulse present 2+. Strong equal hand grip. Capillary refill <3 seconds. Abdomen soft non-tender slightly distendend pt states bowel movement yesterday. Pedal pulses present. Negative Homans sign. Ambulates independently with steady gait.