Date of Admission: September 20, 2021

77 years old, Male, came in to ER for consult due to dyspnea

HPI: 1week PTA noted productive cough associated with shortness of breath, intermittent fever, loss of
smell and taste and body malaise. 1 day PTA noted progressive dyspnea which prompted consult.

PMHx: known hypertensive and diabetic since 2015 with poor compliance to medications, no history of
vaccinations, no known allergy to medications.

PSHx: 30pack years smoker, alcoholic, 4Ps member

ROS: noted previous episode of progressive dyspnea

Vital signs were 120/80, HR-104, RR-33, T-38.0, O2 sat at 88% room air.

Pertinent PE: crackles bilateral, tachycardia, regular rhythm.

Diagnostics done at ER:

Instruction: Based on an actual case above, make a problem list using the format below:

Problem # Status Problem Date Date

(Active/Inactive/Resolved) Started Resolved

Reminders: Submit to my email(jecino.roger.md@gmail.com) with subject name (2 nd year med –

Problem List). It should be submitted before 8:30AM (10/05/2021).