Description

74 y/o male with past medical history of HTN and CAD presents to the office today with complaints of progressive DOE and orthopnea over the last 2-3 months, associated with fatigue and lethargy. Patient reports having to use 3 pillows at night to help improve difficulty breathing. Patient states to have lower leg swelling, which is also worsening. Reports occasional episodes of palpitations. States to have a persistent dry cough, following a cold 3 weeks ago. Patient states over this time has noticed a 15 lb weight gain. Has recently discontinued use of all blood pressure medications 5-6 weeks ago. Denies any sweating, chest pain, wheezing, N/V, dizziness, or headaches.