The 58-year-old patient presents to the clinic for a follow-up appointment. Upon assessment, the nurse notes expiratory wheezes across all lung fields. Review the patient’s chart to determine the most likely cause of this new symptom.

  • Demographics
  • Vital signs
  • Past medical history
  • Medications
  • Assessment

  • Age: 58
    Weight: 245 lb
    Height 5’8”
    Chief complaint: Hypertension

  • Temperature: 37.5°C
    Heart rate: 104 beats per minute
    Respiratory rate: 14 breaths per minute
    Blood pressure: 128/72 mmHg
    Oxygen saturation: 95%

  • Gastroesophageal reflux disease
    Systemic hypertension
    Seasonal allergies

  • Montelukast sodium 10 mg tab once per day
    Omeprazole 20 mg capsule once per day
    Hydrochlorothiazide 25 mg tab once per day
    Atenolol 50 mg tab once per day

  • HEENT: WNL
    Cardiovascular: Hypertension, well controlled. Otherwise WNL.
    Respiratory: Expiratory wheezes bilaterally. No retractions noted. 
    Genitourinary/Gastrointestinal: GERD, well controlled. Otherwise WNL.
    Musculoskeletal: Lordosis noted.
    Nutrition: Obese with a BMI of 37.3.

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