Review of Systems (ROS)
General: Fatigued x 6 months. Denies chills but felt warm the first week of
his illness but didn't check with the thermometer started checking 2 days
ago and had a fever of 101.8°F, Also having night sweats that drenched his
pajamas and sheets. Reports losing 5 lbs in the last couple of weeks. Denies
weight gain, difficulty sleeping, having pets, asbestos exposure, known sick
contacts, recent travel, exposure to high altitudes, or camping.
Skin: Denies skin itching or burning
HEENT: Denies headache, runny nose, nasal congestion, sore throat, post-
nasal drip.
Neck: Reports some tenderness in his neck near his throat.
Respiratory: Constant short of breath for a couple of weeks that he first
noticed when going upstairs at work and home and has been getting
progressively worse. Feels “puny and winded with minimal activity”. Also
has a non-productive constant mild cough that started a few weeks ago at
the same time as the shortness of breath. Tried steamy showers with no
relief. Shortness of breath gets worse with even a little bit of activity he
tried his friend's albuterol inhaler with no relief. Report shortness of breath
is always there even when laying down but it's not as bad when he's resting
and not active. Reports having shortness of breath at rest including right
now. The shortness of breath and cough does not wake him at night but if he
wakes to go pee he may cough and will get short of breath from walking to
the bathroom. Sleeps with one pillow. Denies wheezing, hemoptysis, or
snoring.
Cardiovascular: Denies palpitations or chest pain
Gastrointestinal: Denies nausea/vomiting, change in bowel frequency
Genitourinary: Occasional nocturia
Musculoskeletal: Denies generalized weakness, swelling in any part of body,
Neurological: Denies confusion, dizziness, lightheadedness
PMH:
Diagnosed with HIV but not aids eight years ago and was on an HAART
medication for three years and then stopped taking it cold Turkey due to
roommates making him feel stigmatized but has had no issues in the last
five years since stopping the medications and has no other health issues.
Denies any mental health problems. Denies any history of sleep apnea.
Denies any previous medical surgical or dental procedures. Has never been
, hospitalized. Denies any remarkable childhood illnesses. Denies use of any
other prescription, over the counter, or herbal medications.
NKDA
Gets a physical about every five years. Received all his immunizations as a
child and has received the flu and COVID vaccines earlier this year at a
community outreach health fair
Family hx:
Patient does not have any children. His parents have been divorced for
years.
His mother is 67 years old and was diagnosed with high cholesterol when
she was 55 and is diet controlled. She also has arthritis which she got when
she was 60.
His father is 66 years old and has high blood pressure since he was 49 that
is treated with medications.
His sister is 6 years old and is healthy
Maternal grandparents are healthy except one of them had diabetes.
Does not know his paternal grandparents.
He is a software engineer for a startup tech company. He gets together with
friends after work or catches up with them online. Lives by himself in an
apartment.
He drinks two glasses of wine per week. Does not use recreational drugs
but does smoke cigarettes, half a pack a day but has been a little less since
his SOB started. He started smoking 20 years ago.
Eats fast food about five days a week but tries to limit the really greasy
food. On the other days he likes spaghetti or a sandwich. He snacks on
granola bars or nabs.
HPI:
The patient is a 39-year-old male who presents with progressively
General: Fatigued x 6 months. Denies chills but felt warm the first week of
his illness but didn't check with the thermometer started checking 2 days
ago and had a fever of 101.8°F, Also having night sweats that drenched his
pajamas and sheets. Reports losing 5 lbs in the last couple of weeks. Denies
weight gain, difficulty sleeping, having pets, asbestos exposure, known sick
contacts, recent travel, exposure to high altitudes, or camping.
Skin: Denies skin itching or burning
HEENT: Denies headache, runny nose, nasal congestion, sore throat, post-
nasal drip.
Neck: Reports some tenderness in his neck near his throat.
Respiratory: Constant short of breath for a couple of weeks that he first
noticed when going upstairs at work and home and has been getting
progressively worse. Feels “puny and winded with minimal activity”. Also
has a non-productive constant mild cough that started a few weeks ago at
the same time as the shortness of breath. Tried steamy showers with no
relief. Shortness of breath gets worse with even a little bit of activity he
tried his friend's albuterol inhaler with no relief. Report shortness of breath
is always there even when laying down but it's not as bad when he's resting
and not active. Reports having shortness of breath at rest including right
now. The shortness of breath and cough does not wake him at night but if he
wakes to go pee he may cough and will get short of breath from walking to
the bathroom. Sleeps with one pillow. Denies wheezing, hemoptysis, or
snoring.
Cardiovascular: Denies palpitations or chest pain
Gastrointestinal: Denies nausea/vomiting, change in bowel frequency
Genitourinary: Occasional nocturia
Musculoskeletal: Denies generalized weakness, swelling in any part of body,
Neurological: Denies confusion, dizziness, lightheadedness
PMH:
Diagnosed with HIV but not aids eight years ago and was on an HAART
medication for three years and then stopped taking it cold Turkey due to
roommates making him feel stigmatized but has had no issues in the last
five years since stopping the medications and has no other health issues.
Denies any mental health problems. Denies any history of sleep apnea.
Denies any previous medical surgical or dental procedures. Has never been
, hospitalized. Denies any remarkable childhood illnesses. Denies use of any
other prescription, over the counter, or herbal medications.
NKDA
Gets a physical about every five years. Received all his immunizations as a
child and has received the flu and COVID vaccines earlier this year at a
community outreach health fair
Family hx:
Patient does not have any children. His parents have been divorced for
years.
His mother is 67 years old and was diagnosed with high cholesterol when
she was 55 and is diet controlled. She also has arthritis which she got when
she was 60.
His father is 66 years old and has high blood pressure since he was 49 that
is treated with medications.
His sister is 6 years old and is healthy
Maternal grandparents are healthy except one of them had diabetes.
Does not know his paternal grandparents.
He is a software engineer for a startup tech company. He gets together with
friends after work or catches up with them online. Lives by himself in an
apartment.
He drinks two glasses of wine per week. Does not use recreational drugs
but does smoke cigarettes, half a pack a day but has been a little less since
his SOB started. He started smoking 20 years ago.
Eats fast food about five days a week but tries to limit the really greasy
food. On the other days he likes spaghetti or a sandwich. He snacks on
granola bars or nabs.
HPI:
The patient is a 39-year-old male who presents with progressively
