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68 años de edad
Bogota/bogota
pensionado/mesero
No practicante religion
Vive con esposa y nieta
calidad de informacion regular
MC: " Rengo mucha tos y ahogo"
EA: Paciente masculino de 68 años de edad con cuadro clinico de 3 dias de evolucion consistente en disnea MMRC 2, oxigeno requiriente permanente y tos no productiva, sin hemoptisis, asociado a cefalea intensidad 6/10, sin signos de bandera roja y malestar general, niega pico febril, sintomas urinarios y gastrointestinales u otra sintomatologia.
Revision por sistemas
Niega perdida de peso, disforesis nocturna, fiebre, cardiovascular sensacion de palpitaciones, niega sintomas urinarios, o gastrointestinales
Antecedentes
Patologicos: CIA (cierre 2010 cx abierta), hipertension pulmonar, hipotiroidismo, gastritis, epoc
Farmacologicos: Levotiroxina 75mcg, ASA 100mg, omeprazol 40mg, acetaminofen 1g cada 8h, bromuro de ipratropio 2 puff cada 12h, beclometasona 50mcg 2 puff cada 12 h, oxigeno permanente en casa canula nasal
Alergicos: Niega
Toxicos: Exposicion a humo de cigarrillo durante 28 años
Traumaticos: Amputacion de 4 dedo a los 14 años
Quirurgicos: Herniorrafia inguinal derecha hace 12 años, cateterismo hace 13 años, cateterismo hace 7 años sin colocacion de sten.
Examen fisico
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