NR 603 Week 5 iHuman Virtual Patient Encounter and Reflection - Frank Russo - Progressive Shortness of Breath in HIV Patient

Maternal grandparents- one of them had diabetes Parents divorced History questions 1. Reason for encounter: progressive shortness of breath for the past two weeks 2. History of present illness: FR is a 39-year-old male with a history of untreated HIV who presents with progressive exertional shortness of breath for 2 weeks. Symptoms worsen with minimal activity, such as walking from the bedroom to the kitchen or climbing one flight of stairs and improve with rest. He reports associated fatigue, a nonproductive cough, which was initially productive of clear and white sputum, fever of 101.8 F two days ago, night sweats, and unintentional 5 lbs weight loss. He denies chest pain, wheezing, dizziness, recent travel, or sick contacts. He tried albuterol but it provided no relief. He has not received routine medical care in 5 years and discontinued antiretroviral therapy 5 years ago. Review of systems 1. General- reports fatigue, fever 101.8 F 2 days ago, night sweats, and unintentional weight loss of 5 lbs in last two weeks. Denies dizziness or syncope. 2. HEENT/ Neck- denies sore throat, nasal congestion, rhinorrhea or neck pain. 3. Cardiovascular- denies chest pain, palpitation, paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema 4. Respiratory- progressive shortness of breath with exertion and cough, initially productive cough, now nonproductive. Denies wheezing, hemoptysis, or shortness of breath at rest 5. Gastrointestinal- denies nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits 6. GU- Not assessed 7. Musculoskeletal- denies joint pain, muscle aches, or weakness 8. Neurologic- denies headaches, dizziness, syncope or numbness 9. Integumentary/breast- not assessed 10. Psychiatric- reports concern about symptoms. Denies anxiety, depression or mood changes 11. Endocrine- recent weight loss. Denies heat or cold intolerance. 12. Hematologic/lymphatic- not assessed 2. HEENT/Neck: Head atraumatic and normocephalic. No sinus tenderness. Oropharynx without any lesions or thrush. Dry oral mucus membranes. Neck supple, trachea midline. 3. Cardiovascular: Tachycardia. Regular rhythm. No murmurs, rubs, or gallops. Peripheral pulses palpable and symmetric. No lower extremity edema. 4. Chest/respiratory: use of accessory muscles noted. Chest symmetric without tenderness, masses, heaves, thrills, or crepitus. Percussion resonant throughout. Breath sound present bilaterally and normal. No egophony, bronchophony, or increased whispered pectoriloquy. 5. Abdomen: flat, nondistended. Bowel sounds present in all quadrants. Soft and non-tender to palpation. No guarding, rebound, or masses. 6. GU/rectal: No anal condyloma, perianal lesions, or rectal discharge noted. External genitalia without lesions, ulcers, warts or discharge. 7. Musculoskeletal: normal range of motion in all extremities. No joint swelling, deformity, or tenderness. No calf tenderness or asymmetry. 8. Neurologic: Alert, oriented. Cranial nerves intact. Strength 5/5 in all extremities. 9. Skin: warm, dry skin. No visible rash or lesions. 10. Lymphatic: cervical lymph nodes enlarged at 0.5-2.0 cm, firm anterior and posterior cervical lymph nodes, slightly tender and non-erythematous. 11. Psychiatric: appropriate mood and affect. Though process logical and goal oriented. Expresses concern regarding current symptoms. No acute distress, anxiety, or psychosis. Key findings 1. Progressive exertional SOB for 2 weeks, worsening with minimal activity 2. Conversational dyspnea and